The fungal diagnostic landscape is evolving; whereas previously, traditional culture-based methods dominated, most invasive fungal disease is now diagnosed with non-culture-based tests, including direct microscopy, antigen, antibody, and molecular assays, supported by histopathology and radiology. Access to and turnaround time of diagnostic tests and their clinical implementation varies across the UK. The British Society for Medical Mycology convened an expert group to update its 2015 best practice guidance. Guidance on histopathology and radiology investigations remain unchanged from the 2015 standards of care. For each mycological test, we include test-specific commentaries and accompanying tables, with expected turnaround times (sample collection to reporting). Based on recent evidence, new or stronger recommendations include use of Pneumocystis PCR; 1,3-β-D-glucan testing for suspected invasive candidiasis and Pneumocystis pneumonia; higher volume respiratory sample cultures; Aspergillus antigen or antibody-based testing in expanded clinically vulnerable populations, including patients in intensive care units and patients with chronic respiratory disease (including asthma); use of Candida PCR and Mucorales PCR in specific contexts; pan-fungal PCR and DNA sequencing for fungal identification from positive microscopy or histopathology specimens; and inclusion of posaconazole and isavuconazole in therapeutic antifungal monitoring recommendations. We discuss integration of diagnostic tests with antifungal stewardship and common clinical scenarios. Although recommendations focus on adults and UK practice, use in paediatric populations and worldwide applicability is discussed. Recommendations are presented as auditable standards to facilitate implementation and quality improvement measures. An emphasis on integration of combined diagnostics with antifungal stewardship and clinical pathways extends guideline relevance beyond microbiology laboratories to clinicians investigating patients with multimorbidity and suspected fungal disease within increasingly complex health-care systems.

Background Tuberculosis (TB) diagnosis in the UK is impacted by delay and suboptimal culture-based microbiological confirmation rates due to the high prevalence of paucibacillary disease. We examine the real-world clinical utility of Xpert MTB/RIF Ultra (Xpert-Ultra) as a diagnostic test and biomarker of transmissible infection in a UK TB service. Methods Clinical specimens from suspected TB cases triple tested (smear microscopy, mycobacterial culture and Xpert-Ultra) at University Hospitals of Leicester NHS Trust (1 March 2018-28 February 2019) were retrospectively analysed. Diagnostic sensitivity and specificity were calculated using positive MTB culture and clinical TB diagnosis as reference standards. The QuantiFERON (QFT) positive proportion of pulmonary TB (PTB) contacts was used as a metric of transmitted infection to evaluate Xpert-Ultra and smear grade as markers of infectiousness. Results 251 samples (188 respiratory) from 231 patients (86 TB) were analysed. Compared with microscopy, Xpert-Ultra had higher diagnostic sensitivity (24.7% vs 78.7%, p<0.001) and comparable specificity (97.5% vs 99.4%). Xpert-Ultra and culture had comparable sensitivity (78.7% vs 71.9%) and specificity (99.4% vs 100.0%). Incorporating Xpert-Ultra with culture increased microbiologically verified diagnosis to 91.7% for PTB and 75.9% for extrapulmonary TB, compared with 85.0% and 44.8%, using culture alone. In PTB, both smear and Xpert-Ultra grade were positively associated with the proportion of contacts testing QFT positive. However, Xpert-Ultra had a higher negative predictive value than smear (QFT-positive contacts 6.7% vs 17.7%). Conclusion In low-TB-burden settings, systematic adoption of Xpert-Ultra for clinical assessment of suspected TB can improve the proportion of microbiologically verified diagnoses and improve the stratification of transmission risk.

Introduction Use of rapid molecular diagnostics such as Xpert MTB/RIF and Xpert MTB/RIF Ultra (Xpert-Ultra) is endorsed by World Health Organization for rapid diagnosis of TB. Xpert-Ultra has improved sensitivity, but utility in low TB-prevalent settings, where paucibacillary and extrapulmonary disease are more common, remains uncertain. Current UK National Institute for Health and Care Excellence guidance for use of rapid molecular diagnostics remains unclear. Objectives To examine utility of Xpert-Ultra as a clinical first-line diagnostic tool in pulmonary (PTB) and extrapulmonary TB (EPTB) and to investigate Xpert-Ultra grade as a biomarker of infectiousness in a low TB burden setting. Methods Retrospective analysis of all patients with suspected TB that were triple tested with Xpert-Ultra, smear microscopy and mycobacterial culture at the University Hospitals of Leicester NHS Trust between 01/03/2018 and 28/02/2019. Sensitivity and specificity analyses of all three diagnostic markers were performed using TB culture and TB diagnosis at the primary disease site as independent reference standards. We also investigated the association between Xpert-Ultra grade from index PTB respiratory tract samples, and infectiousness defined as the proportion of close contacts with QuantiFERON-TB Gold plus positive latent TB infection (LTBI). Results 251 samples (188 respiratory samples) were analysed, from 231 patients of whom 86 had TB. 64 samples (63 patients) were Mycobacterium tuberculosis (Mtb) culture positive. 26 samples were smear positive, including four with non-tuberculous mycobacteria. 71 were Xpert-Ultra positive. Compared with culture alone, Xpert-Ultra increased microbiological confirmation of TB diagnosis from 50.0% to 73.1% in EPTB, and from 87.7% to 89.5% in PTB (table 1). Combining both Xpert and culture as a composite for microbiological diagnosis yielded overall sensitivity of 84.6% and 94.7% for the diagnosis of EPTB and PTB, respectively. Overall, 28.6% of 224 screened PTB contacts from 49 PTB cases had LTBI. Stratifying by index Xpert-ultra grade (high/low/negative), the proportion of contacts with LTBI was 45.5%, 17.4% and 4.4% respectively. Conclusions Xpert-Ultra is a highly sensitive and specific TB diagnostic that usefully informs infectiousness of PTB. Our data support using Xpert-Ultra routinely with culture, in the diagnostic assessment of clinically relevant cohorts.

Background: Pneumocystis jirovecii pneumonia (PJP) transmission is poorly defined. Previous studies have sampled air of rooms occupied by HIV-infected patients with PJP, while natural and direct exhalations of HIV-uninfected subjects remain under -investigated. Here, clinical facemasks were used to examine and quantify potential P. jirovecii exhalations from HIV-uninfected patients with suspected PJP and to determine whether pathogen exhalation was definable clinically or radiologically.Methods: Forty-five patients in Leicester (England), highly suspected of having PJP based on European Conference on Infections in Leukaemia (ECIL-5) guidelines, each wore one facemask carrying a gelatine/PVA sampling matrix for 1 h while respiring normally. Mask contamination with P. jirovecii was assessed using a modified quantitative polymerase chain reaction targeting mitochondrial large subunit (MtLSU). Radiological findings on chest X-ray (CXR) and computed tomography (CT) were graded and analysed for correla-tion with P. jirovecii signals alongside relevant clinical and laboratory findings.Results: P. jirovecii was detected in seven of 20 patients diagnosed with PJP and three of 19 patients with suspected but undiagnosed PJP. The median captured signal was 8.59 x 104 MtLSU copies/mask (interquartile range (IQR) = 3.01 x 105-1.81 x 104). Blood b-D-glucan test results correlated with the mask detection data (r = 0.65; P<0.0001) but other clinical indices and radiological features did not. Five of the 10 P. jirovecii-exhalers exhibited normal CXR with a median exhalation burden 1.28 x 105 copies/mask (IQR = 1.51 x 105-2.27 x 104). Two P. jirovecii-exhalers (7.64 x 104 copies/mask) were asymptomatic.Conclusion: P. jirovecii was exhaled sufficiently during normal respiration to be detect-able in facemasks worn by HIV-uninfected patients. Neither clinical nor radiological fea-tures correlated with P. jirovecii exhalation.(c) 2022 The Author(s). Published by Elsevier Ltd on behalf of The Healthcare Infection Society. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Responses to the early (February-July 2020) COVID-19 pandemic varied widely, globally. Reasons for this are multiple but likely relate to the healthcare and financial resources then available, and the degree of trust in, and economic support provided by, national governments. Cultural factors also affected how different populations reacted to the various pandemic restrictions, like masking, social distancing and self-isolation or self-quarantine. The degree of compliance with these measures depended on how much individuals valued their needs and liberties over those of their society. Thus, several themes may be relevant when comparing pandemic responses across different regions. East and Southeast Asian populations tended to be more collectivist and self-sacrificing, responding quickly to early signs of the pandemic and readily complied with most restrictions to control its spread. Australasian, Eastern European, Scandinavian, some Middle Eastern, African and South American countries also responded promptly by imposing restrictions of varying severity, due to concerns for their wider society, including for some, the fragility of their healthcare systems. Western European and North American countries, with well-resourced healthcare systems, initially reacted more slowly, partly in an effort to maintain their economies but also to delay imposing pandemic restrictions that limited the personal freedoms of their citizens.

Based on data extracted from Worldometer: https://www.worldometers.info/coronavirus/

Antimicrobial stewardship programs focus on reducing overuse of broad-spectrum antibiotics (BSAs), primarily through interventions to change prescribing behavior. This study aims to identify multi-level influences on BSA overuse across diverse high and low income, and public and private, healthcare contexts. Semi-structured interviews were conducted with 46 prescribers from hospitals in the UK, Sri Lanka, and South Africa, including public and private providers. Interviews explored decision making about prescribing BSAs, drivers of the use of BSAs, and benefits of BSAs to various stakeholders, and were analyzed using a constant comparative approach. Analysis identified drivers of BSA overuse at the individual, social and structural levels. Structural drivers of overuse varied significantly across contexts and included: system-level factors generating tensions with stewardship goals; limited material resources within hospitals; and patient poverty, lack of infrastructure and resources in local communities. Antimicrobial stewardship needs to encompass efforts to reduce the reliance on BSAs as a solution to context-specific structural conditions.

Background Candida auris is an emerging multidrug-resistant fungal pathogen associated with bloodstream, wound and other infections, especially in critically ill patients. C. auris carriage is persistent and is difficult to eradicate from the hospital environment. Aim We aimed to pilot admission screening for C. auris in intensive care units (ICUs) in England to estimate prevalence in the ICU population and to inform public health guidance. Methods Between May 2017 and April 2018, we screened admissions to eight adult ICUs in hospitals with no previous cases of C. auris, in three major cities. Swabs were taken from the nose, throat, axilla, groin, perineum, rectum and catheter urine, then cultured and identified using matrix-assisted laser desorption/ionisation time-of-flight mass spectrometry (MALDI-TOF MS). Patient records were linked to routine ICU data to describe and compare the demographic and health indicators of the screened cohort with a national cohort of ICU patients admitted between 2016 and 2017. Results All C. auris screens for 921 adults from 998 admissions were negative. The upper confidence limit of the pooled prevalence across all sites was 0.4%. Comparison of the screened cohort with the national cohort showed it was broadly similar to the national cohort with respect to demographics and co-morbidities. Conclusion These findings imply that C. auris colonisation among patients admitted to ICUs in England is currently rare. We would not currently recommend widespread screening for C. auris in ICUs in England. Hospitals should continue to screen high-risk individuals based on local risk assessment.

Dengue is an arboviral disease transmitted principally by two vectors Aedes aegypti and Aedes albopictus. In the absence of a successful prophylaxis or treatment, the disease control relies solely on vector control. Therefore, the knowledge on vector population genetics can play an important role in designing efficient vector control strategies especially during the release of Wolbachia transinfected mosquitoes. As such, we investigated the population genetic structure of Ae. aegypti and Ae. albopictus in Sri Lanka covering seven (Colombo, Gampaha, Kalutara, Galle, Jaffna, Mullathivu and Kilinochchi) dengue endemic regions using six microsatellite markers specific for each species to provide baseline data to implement Wolbachia control method. According to the results, both species revealed small but significant population structure. The genetic structure observed for Ae. albopictus populations was more subtle compared to that of Ae. aegypti reflecting their comparatively high geneflow over long distances. Evidence for possible multiple invasions towards the northern part of the country from the southern Ae. albopictus populations facilitated by increased human activity and urbanization were also apparent. On the contrary, the dispersal of Ae. aegypti was observed to be more restricted especially between north and south parts of the country. The genetic diversity and effective population number was also greater for Ae. albopictus compared to Ae. aegypti indicating their relatively higher evolutionary potential and adaptability. As a whole, our study suggests that the scheduled dengue control measurers using Wolbachia infected mosquitoes need to cover both vector species based on their species specific geneflow patterns to yield an effective dengue control.

Overuse of broad-spectrum antibiotics in secondary care is a key contributor to the emergence and spread of antimicrobial resistance (AMR); efforts are focused on minimizing antibiotic overuse as a crucial step toward containing the global threat of AMR. The concept of overtreatment has, however, been difficult to define. Efforts to address the overuse of medicine need to be informed by an understanding of how prescribers themselves understand the problem. We report findings from a qualitative interview study of 46 acute care hospital prescribers differing in seniority from three countries: United Kingdom, Sri Lanka and South Africa. Prescribers were asked about their understanding of inappropriate use of antibiotics. Prescriber definitions of inappropriate use included relatively clear-cut and unambiguous cases of antibiotics being used “incorrectly” (e.g., in the case of viral infections). In many cases, however, antibiotic prescribing decisions were seen as involving uncertainty, with prescribers having to make decisions about the threshold for appropriate use. Decisions about thresholds were commonly framed in moral terms. Some prescribers drew on arguments about their duty to protect public health through having a high threshold for prescribing, while others made strong arguments for prioritizing risk avoidance for the patients in front of them, even at a cost of increased resistance. Notions of whether prescribing was inappropriate were also contextually dependent: high levels of antibiotic prescribing could be seen as a rational response when prescribers were working in challenging contexts, and could be justified in relation to financial and social considerations. Inappropriate antibiotic use is framed by prescribers not just in clinical, but also in moral and contextual terms; this has implications for the design and implementation of antibiotic stewardship interventions aiming to reduce inappropriate use of antibiotics globally.

Sunbirds (Passeriformes: Nectariniidae) are small passerines that feed largely on nectar. The aim of this work was to study the occurrence of sunbirds in different habitats, to observe and describe their activity frequencies, to observe the relationship of the Long-billed sunbird Cinnyris lotenius and Purple-rumped sunbird Leptocoma zeylonica with their host flowers, and to examine their behavioral relationships with the colour of the flower, flower count, nectar glucose concentration and the length of corolla of flowers. The study was carried out in five different habitat types in the Kandy district, Sri Lanka: a forest reserve, home garden habitats at two widely separated locations, a roadside habitat, and a botanical garden. The study was carried out between March and September 2013. Results show that during the day, sunbirds spent most of their time in foraging than in acquiring food. In the study, 21 different plants were recognized as nectar feeding plants for sunbirds. The number of visits by sunbirds did not depend on the plant species or the colour of the flower. The results also indicated that the correlation between the flower count and the occurrence of the Long-billed sunbird was not significant. However, there was a significant correlation between the flower count and the occurrence of the Purple-rumped sunbird. Furthermore, there was a significant correlation with the glucose concentration and the occurrence of the Long-billed sunbird; whereas no such correlation between the glucose concentration and the occurrence of Purple-rumped sunbird. There was no significant correlation with the length of corolla and the occurrence of the Long-billed sunbird, but there was a significant correlation in occurrence of Purple-rumped sunbird and the length of corolla. These correlations are due to the difference in their body size and bill length. The difference in feeding plants is due to their bill length and that allows both of them to share a common habitat.

Background & objectives: Aedes aegypti is the most prominent vector for dengue virus worldwide. Accurate identification of the species and understanding its colonization pattern are essential prerequisites in vector control. Thus, the present study was aimed to genetically characterize Ae. aegypti mosquitoes collected from different regions of Sri Lanka based on mitochondrial COI gene. Methods: Thirty-three Ae. aegypti larval samples were collected from 19 districts. A 735bp region of the mitochondrial COI gene was amplified and analyzed for genetic diversity indices. Phylogenetic trees were constructed using Sri Lankan samples and also including mosquito samples reported from other parts of the world. Results: High genetic diversity was observed within the samples analysed (gene diversity: 0.949; average number of nucleotide differences: 6.371). There were 20 haplotypes presented within the 19 localities investigated. The phylogenetic tree derived two main clades. However, no distinguishable clustering pattern was observed in the phylogenetic tree except for the districts in the northern corner indicating extensive admixing among different populations. When samples from other countries were included in the phylogenetic tree, Anuradhapura, and Mannar samples were clustered together with samples from India, Venezuela, USA, Portugal and Cambodia while Rathnapura was clustered with Bolivia and France. Interpretation & conclusion: Our results suggest that Sri Lanka has undergone multiple invasions of Ae. aegypti from various parts of the world over an extensive period. Further, the mosquito control campaigns had not caused a significant effect on the Ae. aegypti populations which is existing in mutation-drift equilibrium.

Background: Bone marrow transplantation (BMT) is a unique immunosuppressed state, and the consequences of infection are often severe. We hypothesized that disruption of the faecal microbiota (such as with use of broad spectrum antibiotics) may predispose to gastrointestinal related sepsis post bone marrow transplantation. Methods: We reviewed the laboratory data from all BMT patients between January 2016 and August 2018 and recorded the presence of bacteraemia. We matched these patients to controls with no recorded bacteraemia. We then recorded antibiotic exposure in the immediate pre-transplant period. Results: 238 records were reviewed (81 allografts, 157 autografts). We identified 28 patients with bacteraemia from gastrointestinal related pathogens. 28 controls with no positive blood cultures were matched according to the type of BMT. In both groups there were 18 allografts, 12 of which were matched unrelated donors. In the bacteraemic group there were a total of 12 antibiotic episodes (60 days) pre-transplant, compared with 6 (41 days) in the control group. The most common antibiotics used were meropenem (47 days in the bacteraemic group, 24 control) and piperacillin/tazobactan (13 days in the bacteraemic group, 3 control). Conclusion: Our results support the hypothesis that broad spectrum antibiotics pre-transplant may predispose to post-transplant sepsis. Although the small population size limits this study, further studies are necessary to confirm this finding, and to investigate which components of the faecal microbiota are the most important to preserve prior to BMT. This may open the door to novel therapeutics in this patient group, such as faecal microbiota transplant.

Dengue fever has been endemic to Sri Lanka for several decades. Due to the unavailability of an established prophylactic medicine, dengue prevention depends largely on vector control, where vector surveillance plays a key role. The present study aimed to assess the Aedes mosquito abundance and the risk of disease outbreak using ovitrap surveillance in 14 areas in Sri Lanka, covering four districts with high dengue incidence during 2014 – 2016. A total of 1537 ovitraps were placed in Colombo (Kirulapone, Dematagoda, Grandpass and Thummulla), Gampaha (Kurana and Imbulgoda), Kalutara (Horana, Keselwaththa and Kalamulla) and Kandy (Nawalapitiya, Peradeniya, Edanduwawa, Hanthana Road and Thalwaththa) districts in both indoor and outdoor sites and were collected after five days. The larval counts were used to calculate the Container Index (CI) and Ovitrap Index (OI). Our results revealed significantly higher CI for Aedes species for outdoor compared to indoor sites, indicating a tendency of Ae. aegypti and Ae. albopictus to breed more in outdoor habitats (p < 0.05). In most co-bred ovitraps, the number of Ae. aegypti larvae were higher than those of Ae. albopictus. The abundance of Ae. aegypti was higher in urban areas compared to rural areas (p < 0.05) whereas no such difference was observed for Ae. albopictus. This suggests that Ae. albopictus has been successful in invading habitats with different levels of urbanization. Further, all studied areas showed an OI > 10 % for either or both Aedes species reflecting a possible risk of dengue outbreaks as per the guidelines. Nevertheless, only the abundance of Ae. aegypti (in terms of OI) showed a positive correlation with the number of dengue cases (r = 0.96, p < 0.05) indicating its substantial contribution towards dengue incidences in the studied areas.

BackgroundAntimicrobial resistance (AMR) is one of the greatest threats in 21st century medicine. AMR has been characterized as a social dilemma. A familiar version describes the situation in which a collective resource (in this case, antibiotic efficacy) is exhausted due to over-exploitation. The dilemma arises because individuals are motivated to maximize individual payoffs, although the collective outcome is worse if all act in this way.ObjectivesWe aim to outline the implications for antimicrobial stewardship of characterizing antibiotic overuse as a social dilemma.SourcesWe conducted a narrative review of the literature on interventions to promote the conservation of resources in social dilemmas.ContentThe social dilemma of antibiotic over-use is complicated by the lack of visibility and imminence of AMR, a loose coupling between individual actions and the outcome of AMR, and the agency relationships inherent in the prescriber role. We identify seven strategies for shifting prescriber behaviour and promoting a focus on the collectively desirable outcome of conservation of antibiotic efficacy: (1) establish clearly defined boundaries and access rights; (2) raise the visibility and imminence of the problem; (3) enable collective choice arrangements; (4) conduct behaviour-based monitoring; (5) use social and reputational incentives and sanctions; (6) address misalignment of goals and incentives; and (7) provide conflict resolution mechanisms.ImplicationsWe conclude that this theoretic analysis of antibiotic stewardship could make the problem of optimizing antibiotic prescribing more tractable, providing a theory base for intervention development.

Summary Background Antimicrobial resistance is a global health threat, partly driven by inappropriate antibiotic prescriptions for acute medical patients in hospitals. Aim To provide a systematic review of qualitative research on antibiotic prescribing decisions in hospitals worldwide, including broad-spectrum antibiotic use. Methods A systematic search of qualitative research on antibiotic prescribing for adult hospital patients published between 2007 and 2017 was conducted. Drawing on the Health Belief Model, a framework synthesis was conducted to assess threat perceptions associated with antimicrobial resistance, and perceived benefits and barriers associated with antibiotic stewardship. Findings The risk of antimicrobial resistance was generally perceived to be serious, but the abstract and long-term nature of its consequences led physicians to doubt personal susceptibility. While prescribers believed in the benefits of optimizing prescribing, the direct link between over-prescribing and antimicrobial resistance was questioned, and prescribersu0027 behaviour change was frequently considered futile when fighting the complex problem of antimicrobial resistance. The salience of individual patient risks was a key barrier to more conservative prescribing. Physicians perceived broad-spectrum antibiotics to be effective and low risk; prescribing broad-spectrum antibiotics involved low cognitive demand and enabled physicians to manage patient expectations. Antibiotic prescribing decisions in low-income countries were shaped by a context of heightened uncertainty and risk due to poor microbiology and infection control services. Conclusions When tackling antimicrobial resistance, the tensions between immediate individual risks and long-term collective risks need to be taken into account. Efforts to reduce diagnostic uncertainty and to change risk perceptions will be critical in shifting practice.

Antimicrobial resistance is a global health threat, partly driven by inappropriate antibiotic prescriptions for acute medical patients in hospitals.To provide a systematic review of qualitative research on antibiotic prescribing decisions in hospitals worldwide, including broad-spectrum antibiotic use.A systematic search of qualitative research on antibiotic prescribing for adult hospital patients published between 2007 and 2017 was conducted. Drawing on the Health Belief Model, a framework synthesis was conducted to assess threat perceptions associated with antimicrobial resistance, and perceived benefits and barriers associated with antibiotic stewardship.The risk of antimicrobial resistance was generally perceived to be serious, but the abstract and long-term nature of its consequences led physicians to doubt personal susceptibility. While prescribers believed in the benefits of optimizing prescribing, the direct link between over-prescribing and antimicrobial resistance was questioned, and prescribers' behaviour change was frequently considered futile when fighting the complex problem of antimicrobial resistance. The salience of individual patient risks was a key barrier to more conservative prescribing. Physicians perceived broad-spectrum antibiotics to be effective and low risk; prescribing broad-spectrum antibiotics involved low cognitive demand and enabled physicians to manage patient expectations. Antibiotic prescribing decisions in low-income countries were shaped by a context of heightened uncertainty and risk due to poor microbiology and infection control services.When tackling antimicrobial resistance, the tensions between immediate individual risks and long-term collective risks need to be taken into account. Efforts to reduce diagnostic uncertainty and to change risk perceptions will be critical in shifting practice.

We read with interest the recent article in this journal by Al-Siyabi et al. who described the first cases of Candida auris in Oman. 1 Al-Siyabi T Al Busaidi I Balkhair A Al-Muharrmi Z Al-Salti M Al'Adawi B First report of Candida auris in Oman: clinical and microbiological description of five candidemia cases. J Infect. 2017; 75: 373-376 Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar Candida auris is an emerging multi-drug resistant fungal pathogen. It was first described in Japan in 2009 but has since been reported worldwide, including large nosocomial outbreaks in five continents. It is associated with bloodstream, wound, and other infections, especially in critically ill patients. Hospital outbreaks reported to date have proven difficult to control despite enhanced infection control measures. In England, 221 cases have been reported between 2013 and 2017 (160 colonisations and 61 infections including 30 candidaemias) across 20 hospitals with three significant outbreaks in specialist units. 2 Kohlenberg A Struelens MJ Monnet DL Plachouras D The Candida auris survey collaborative group Candida auris: epidemiological situation, laboratory capacity and preparedness in European Union and European Economic Area countries, 2013 to 2017. Euro Surveill. 2018; 23https://doi.org/10.2807/1560-7917.ES.2018.23.13.18-00136 Crossref PubMed Scopus (55) Google Scholar , 3 Public Health England. The characteristics, diagnosis and management of Candida auris (C. auris) 2017 Available from: https://www.gov.uk/government/collections/candida-auris. Google Scholar

The journal is the official publication of the College of Surgeons of Sri Lanka. Its mission is to reach the highest standard of scientific surgical practice by dissemination of high quality scientific information and to foster and promote the growth of scientific surgery in Sri Lanka and in the region. The Sri Lanka Journal of Surgery publishes peer reviewed leading articles, review articles, original articles, research papers and case reports in the field of surgery and broadly related surgical sciences. The journal adheres to the publication ethics as portrayed by the Committee on Publication Ethics (COPE) and is a member of this organisation. It is listed as an ICMJE journal which follow its recommendations (ICMJE recommendations) on Conduct, Reporting, Editing and Publication of Scholarly Work in Medical Journals.