Background:We assessed the diagnostic agreement of BioFire FilmArray multiplex polymerase chain reaction (PCR) with Seegene Allplex PCR for testing fecal samples collected during a diarrhea outbreak in resource-limited settings. Methods:Fecal samples from consented British military personnel training in Kenya were collected without preservative and tested onsite with the FilmArray PCR platform. Anonymized corresponding samples frozen near the point of care were tested 16-18 months later in the United Kingdom using Seegene PCR (reference standard). We compared test sensitivity and specificity and assessed agreement using Cohen κ coefficients. Results:Samples were analyzed from 60 individuals (80% male; median age [interquartile range], 24 [22-28] years). The overall pathogen detection rates did not differ significantly between FilmArray and Seegene PCR (55 of 60 [91.7%] vs 53 of 59 [89.8%], respectively [P > .9]). Campylobacter spp detection was significantly higher with Seegene (17 of 59 [28.8%] vs 6 of 60 [10%] for FilmArray PCR P = .03). The sensitivity of FilmArray PCR was moderate for Cryptosporidium spp (65% [95% confidence interval, 45.37%-80.77%]), and low for Campylobacter spp (35.3% [14.21%-61.67%%) and norovirus (7.14% [.18%-33.87%]). Its specificity was good to excellent for detection of Campylobacter spp, Cryptosporidium spp, enteroaggregative Escherichia coli, and sapovirus. Conclusions:The study shows moderate concordance of FilmArray with Seegene PCR in the detection of 5 enteropathogens and poor to fair concordance for 7 others, but high-quality case-control studies are needed to assess agreement between these platforms. However, based on performance characteristics, including platform versatility and ease of use, and in the absence of a gold (reference) standard test, the FilmArray platform remains a suitable near-patient field-expedient platform for diarrhea diagnostics in resource-limited settings.

INTRODUCTION:Traveller's diarrhoea is a common complaint among deployed military personnel. Maintaining sample integrity prior to diagnostic testing is a key challenge in resource-limited environments. We report the comparison of three long-term ambient temperature stool sample stabilisation matrices for the detection of Cryptosporidium hominis from samples collected during an outbreak among British military personnel stationed in Kenya. METHODS:A retrospective cohort of stool samples, each stabilised for more than 12 months at ambient temperatures using Flinders Technical Associate (FTA) cards, OMNIgene GUT tubes and DNA Shield faecal collection tubes, were analysed by Nanopore-based clinical metagenomic (CMgs) DNA sequencing and quantitative real-time PCR (qPCR) in the UK. The results were compared with BioFire FilmArray Gastrointestinal Panel testing carried out at the point of sampling in Kenya. RESULTS:Cryptosporidium DNA was detected in 13/24 (54.2%) OMNIgene GUT samples by CMg following long-term storage, compared with 9/24 (37.5%) of DNA Shield samples. Samples stored on FTA cards did not identify Cryptosporidium DNA by CMg in any sample. OMNIgene GUT samples also had the highest rate of detection of C. hominis DNA by qPCR, with 23/24 samples testing positive, compared with 21/24 and 17/20 of DNA Shield and FTA samples, respectively. CONCLUSIONS:Samples stored in OMNIgene GUT tubes retained detectable levels of Cryptosporidium DNA in a higher proportion of samples following long-term storage. This study demonstrates the importance of selecting the optimal sample collection and stabilisation matrix for CMg and qPCR based diagnostic testing in austere environments.

BackgroundGastrointestinal illnesses are common during military training and operational deployments. We compared the incidence and burden of travellers’ diarrhoea (TD) reported by British service personnel (SP) during recent training exercises in Kenya and Oman.MethodsSP completed a validated anonymous questionnaire regarding clinical features of any diarrhoeal illness, associated risk factors and impact on work capability after 6-week training exercises in 2018 in Kenya and 2018–2019 in Oman. Responses were tabulated for descriptive comparisons.ResultsQuestionnaires were received from 388 (32%) SP in Kenya and 627 (52%) in Oman. The cumulative incidence of reported diarrhoea over 6-weeks was 14.2% (95% CI 8.02% to 22.61%) in Kenya compared with 3.9% (95% CI 1.10% to 9.91%) in Oman (OR 3.56, 95% CI 2.18 to 5.8; p<0.0001). Attack rates were 9.45 SP/100 exposure-months in Kenya and 2.66/100 in Oman. The number of workdays lost was greater in Kenya (6.26 per 1000 days) compared with Oman (4.13 per 1000 days) (p<0.01). In Kenya, 52.3% of those experiencing diarrhoea became ill during the first 14 days of deployment, but in Oman, 50% were ill in the last deployment week. The strongest risk factor associated with TD at both locations was contact with a colleague experiencing diarrhoea, followed in Kenya by eating locally sourced food and swimming in local water, which had weaker protective associations in Oman.ConclusionsThe epidemiology, risk factors and burden of TD in Kenya were similar to previous descriptions, where overall incidence continues to decline. Incidence and burden were significantly lower in Oman, where both were much lower than historical descriptions. Peak timing of illness and associated risk factors differed between Kenya and Oman. Continued documentation and review of TD during training exercises at different geographical locations is essential to inform the chain of command about risks to operational effectiveness.

INTRODUCTION:Travel to resource-limited settings is a known risk for acquisition of extended-spectrum β-lactamase-producing Enterobacterales (ESBL-PE) and carbapenem-resistant Enterobacterales (CRE), which are both associated with increased morbidity and mortality. We investigated the ESBL-PE and CRE baseline prevalence in British service personnel (SP). METHODS:SP provided faecal samples for research projects in several different settings, between September 2021 and April 2022. Bacterial colonies from faecal isolates were recovered from incubated ChromID ESBL plates (bioMérieux, Marcy-l'Étoile, France) and DNA extracted using Qiagen DNeasy extraction kits (Qiagen, UK). PCR to identify β-lactamase and CRE encoding genes was performed using the Rotor-Gene Q (RGQ) (Qiagen, UK), with positivity detected by RGQ software. Phenotypic assessment of antimicrobial susceptibility was not performed. RESULTS:Out of 250 personnel approached, 239 (85.5% men, median (IQR) age 31 (26-37) years) provided faecal samples suitable for analysis. The ESBL prevalence was 40/239 (16.7%), with ESBL-producing Escherichia coli detected in 39 (16.3%) samples and ESBL-producing Klebsiella pneumoniae in 1 (0.4%) sample. Combinations including Temoniera, sulfhydryl reagent variable (SHV), cefotaxime hydrolysing β-lactamase (Munich) (CTX-M) 1 and CTX-M 9 genes were detected in 18 (7.5%), 33 (13.8%) 16 (6.7%) and 8 (3.3%) samples, respectively. E. coli samples had mixtures of all four genotypes with SHV predominating. One (0.4%) sample carried all four gene types and the only K. pneumoniae sample carried a single SHV gene. No CRE were detected. CONCLUSIONS:The prevalence of ESBL-PE in cohorts of SP closely matches that of civilian populations in England; however, we noted differences in ESBL genotype distribution. Potential exposure risks for SP from international travel and occupational trauma emphasise the need for repeated surveillance to characterise and detect changes in acquisition epidemiology and carriage of ESBL. Such prospective data have important antimicrobial stewardship implications in optimising clinical outcomes, controlling resistance and guiding empirical antibiotic formulary policy recommendations.

Gastrointestinal parasite (GIP) infections are of major military importance. They have been frequently diagnosed post-deployment and can have debilitating sequelae.1–4 Some, such as Strongyloides, are often asymptomatic before presenting as severe disease, which has been fatal in veterans.5 6Whilst the UK Armed Forces recruit many personnel from endemic countries, few are offered testing. Furthermore, despite extensive Defence activity in endemic areas, data on post deployment prevalence is scarce. A total of 437 participants were recruited from three groups: 250 personnel from Fiji, 119 recently returned from jungle training in Brunei (tested at 2- and 12-weeks post-return), and 68 with historical deployments to Brunei. Participants were tested for GIP using serum for Strongyloides serology, full blood counts, and faeces for microscopy, culture, and qPCR. High GIP infection rates, particularly Strongyloides, were observed across all groups. Amongst Fijian migrants, 35.1% (87/248) had positive Strongyloides serology and 18.9% (14/74) had GIP in faeces. In personnel recently returned from Brunei, 56.0% (65/116) had a positive faecal test for GIP, with 47.4% (55/116) positive for Strongyloides. Serological testing in this group was insensitive (16%), and sequencing revealed infection with Strongyloides fuelleborni and callosciureus. In Group 3, 17.6% (12/68) had a positive Strongyloides result, with the longest infection lasting over 5 years. The novel findings of this project have uncovered a high GIP burden in Armed Forces personnel. The prevalence of Strongyloides found in this first ever study of Fijian migrants has significant public health implications and has prompted steps to offer testing to all Fijian personnel. This study is also the first globally on imported S. fuelleborni infection, revealing previously unknown limitations of serology, and is the first to identify human infection with S. callosciureus. The stark findings demonstrate the uniquely military risk these parasites present and have immediately impacted clinical practice and policy. Bailey M, Thomas R, Green A, Bailey J, Beeching N. Helminth infections in British troops following an operation in Sierra Leone. Transactions of the Royal Society of Tropical Medicine and Hygiene 2006;100(9):842–6. Genta RM, Weesner R, Douce RW, Huitger-O’Connor T, Walzer PD. Strongyloidiasis in US veterans of the Vietnam and other wars. JAMA 1987;258(1):49–52. Gill GV, Bell DR. Strongyloides stercoralis infection in former Far East prisoners of war. Br Med J. 1979;2(6190):572–4. Lee VJ, Ong A, Lee NG, Lee WT, Fong KL, Lim PL. Hookworm infections in Singaporean soldiers after jungle training in Brunei Darussalam. Trans R Soc Trop Med Hyg. 2007;101(12):1214–8. Gill G, Beeching N, Khoo S, Bailey J, Partridge S, Blundell J, et al. A British second world war veteran with disseminated strongyloidiasis. Transactions of the Royal Society of Tropical Medicine and Hygiene 2004;98(6):382–6. Hakim SZ, Genta RM. Fatal disseminated strongyloidiasis in a Vietnam War veteran. Arch Pathol Lab Med. 1986;110(9):809–12.

Introduction. Immediate identification of travellers’ diarrhoea-causing pathogens may not be possible in remote settings, but samples can be stored for epidemiological and related research. We collected pilot data to evaluate the utility of three different preservation media for testing stored faecal samples compared to immediate testing of fresh samples using the BioFire ® FilmArray ® multiplex PCR gastrointestinal panel (bioMérieux). Gap statement. No previous studies have demonstrated the utility of testing faecal samples directly by PCR BioFire ® FilmArray ® following prolonged storage and transportation in OMNIgene ® , DNA ™ shield and FTA ™ cards. Aims. To evaluate the reliability of OMNIgene ® , DNA shield ™ and FTA ™ card faecal storage and transport media in parallel, compared to initial testing of fresh faeces obtained from the same individuals at the time of presentation with diarrhoea in the field compare the results of faecal samples stored and transported at ambient temperature in OMNIgene ® , DNA shield ™ and FTA ™ cards then tested using PCR BioFire ® FilmArray ® 6–18 months later with those obtained from fresh faecal samples during a diarrhoea outbreak. Methodology. Fresh faecal samples were obtained from British military personnel who developed diarrhoea during deployment to Kenya between February-April 2022. Unpreserved fresh samples were tested onsite using PCR BioFire ® FilmArray ® and corresponding samples were stored at ambient temperature in OMNIgene ® 200 (DNAgenotek ® ), DNA/RNA shield DX ™ (Zymo Research) and Whatman FTA™ Elute cards (GE Healthcare) then repatriated to the UK for direct testing by PCR BioFire ® FilmArray ® , 6-18 months later. The most common enteropathogens evaluated were: Cryptosporidium spp., Enteroaggregative Escherichia coli ( E. coli ; EAEC), Enteropathogenic E. coli (EPEC), Shiga toxin-producing E. coli (STEC) and Campylobacter spp. Test results for the three storage modalities were compared to the fresh sample tests as a reference standard. Results. Samples from 60 individuals [80% male; median (interquartile range) age 24 (22–28) years] were analysed. Test sensitivity for Campylobacter spp. and EAEC was high across all three storage modalities (86.4–100%). OMNIgene ® 200 and DNA/RNA shield ™ showed significant concordance with the reference standard test for other pathogens, but FTA ™ Elute card tests had low sensitivity for STEC and poor specificity for Campylobacter spp. Agreement between FTA ™ Elute cards and the reference standard test was low-moderate (kappa coefficient ≤0–0.49) for all enteropathogens. Conclusions. This study demonstrates successful PCR BioFire ® FilmArray ® utility in testing samples stored in different media and is the first to compare the use of OMNIgene ® 200, DNA/RNA shield ™ and FTA ™ Elute cards simultaneously with the results of clinical samples. Stored samples were tested up to 18 months later with significant concordance observed in OMNIgene ® 200 and DNA/RNA shield ™ compared to reference standard testing. The distorted performance of FTA ™ Elute card testing requires further optimisation. Testing of samples stored in these media is suitable for research studies, but their applicability with other molecular diagnostic platforms, or clinical diagnostics, requires confirmation.

Background We report clinical, epidemiological, and laboratory features of a large diarrhea outbreak caused by a novel Cryptosporidium hominis subtype during British military training in Kenya between February and April 2022.Methods Data were collated from diarrhea cases, and fecal samples were analyzed on site using the multiplex polymerase chain reaction (PCR) BioFire FilmArray. Water was tested using Colilert kits (IDEXX, UK). DNA was extracted from feces for molecular characterization of Cryptosporidium A135, Lib13, ssu rRNA, and gp60 genes.Results One hundred seventy-two of 1200 (14.3%) personnel at risk developed diarrhea over 69 days. One hundred six primary fecal samples were tested, and 63/106 (59.4%; 95% CI, 0.49%-0.69%) were positive for Cryptosporidium spp. Thirty-eight had Cryptosporidium spp. alone, and 25 had Cryptosporidium spp. with >= 1 other pathogen. A further 27/106 (25.5%; 95% CI, 0.18%-0.35%) had non-Cryptosporidium pathogens only, and 16/106 (15.1%; 95% CI, 0.09%-0.23%) were negative. C. hominis was detected in 58/63 (92.1%) Cryptosporidium spp.-positive primary samples, but the others were not genotypable. Twenty-seven C. hominis specimens were subtypable; 1 was gp60 subtype IeA11G3T3, and 26 were an unusual subtype, ImA13G1 (GenBank accession OP699729), supporting epidemiological evidence suggesting a point source outbreak from contaminated swimming water. Diarrhea persisted for a mean (SD) of 7.6 (4.6) days in Cryptosporidium spp. cases compared with 2.3 (0.9) days in non-Cryptosporidium cases (P = .001).Conclusions Real-time multiplex PCR fecal testing was vital in managing this large cryptosporidiosis outbreak. The etiology of a rare C. hominis gp60 subtype emphasizes the need for more genotypic surveillance to identify widening host and geographic ranges of novel C. hominis subtypes.

Background: Crimean-Congo hemorrhagic fever (CCHF) is a major emerging infectious disease threat, and children are reported to have a milder disease course compared with adults, in contrast to other viral hemorrhagic fevers. The aim of this study was to compare adult and pediatric patients with CCHF to improve understanding of pathogenesis and the natural history of the disease. Materials and Methods: A retrospective analysis of all children and adults admitted with confirmed CCHF between 2011 and 2020. Epidemiological, clinical, and laboratory features were collated on proformas, together with clinical management details. The Severity Grading Score (SGS) system was used to stratify mortality risk. Data from children were compared with adults in the same center and with other published pediatric cohort studies. Results: A total of 47 children with a median (ranges) age of 14 (2-17) years and 176 adults with a median (ranges) age of 52 (18-83) years with confirmed CCHF were included. The most frequent symptoms in adults were fever, muscle-joint pain, headache, nausea, and vomiting; the most frequent in children were fever, anorexia, nausea, vomiting, and abdominal pain. Adults had lower lymphocyte and platelet counts and higher liver transaminase and creatinine levels than children. SGS values were lower in children, but 97.9% children received ribavirin compared with 8.5% of adults (p < 0.001), and they had associated longer median lengths of hospital admission (10 vs. 7 days, p < 0.001). Mortality of 1 out of 47 (2.1%) children was similar to 11 other cohorts reported in Türkiye and lower than 13.1% in adults (23/176) in the same center (p = 0.059). Conclusions: Children have lower CCHF-related mortality, less severe disease, and different clinical syndromes at presentation. The majority of published case definitions for screening for CCHF in the main endemic countries do not differentiate between adults and children and omit four of the five most common presenting features in children.

BACKGROUND:We evaluated the results of examining a single faecal sample for gastrointestinal parasites (GIP) using a combination of traditional methods with multiplex qPCR for helminths and protozoa, compared to a reference standard of examining three faecal samples from each person using traditional diagnostic methods alone. METHODS:Three faecal samples were collected at weekly intervals from 596 healthy Nepalese men. Each sample underwent formalin-ethyl acetate (FEA) concentration and light microscopy, and charcoal culture. The combined results of these investigations for all three stool samples were designated the reference standard. The first sample was also analysed using a multiplex TaqMan™ qPCR assay, screening for five helminths and three protozoa. We compared sensitivity and specificity of analysing the first faecal sample with qPCR alone, or a hybrid approach combining qPCR with traditional methods, to the reference standard. Additionally, a serum sample was taken from each participant for Strongyloides stercoralis IgG ELISA. RESULTS:The reference standard identified 139 GIP infections in 133 (22.3%) participants. Use of qPCR alone in one stool identified 176 infections in 147 (24.8%) participants, rising to 187 infections in 156 (26.3%) when combined with FEA microscopy and charcoal culture. The sensitivity of this latter hybrid approach was 100% for Strongyloides spp., 90.9% for Trichuris trichiura, 86.8% for hookworm species and 75% for Giardia duodenalis compared to the reference standard. The hybrid approach increased the detected prevalence of G. duodenalis by 4.5% (27 cases) overall, T. trichiura by 2.9% (17 cases), Strongyloides spp. by 1% (6 cases), and hookworm by 0.5% (3 cases), compared to the reference standard. CONCLUSION:Examination of a single faecal sample using qPCR alone showed superior or equivalent sensitivity to traditional methods for most GIP infections when both were compared to the reference standard. Combining molecular and traditional methods to analyse a single stool improved the detection rate for most studied parasites. This approach has value in settings where repeated sampling and/or faecal culture for helminths is impractical, but molecular diagnostics are available.

OBJECTIVES:The objectives were to determine the structure of training programmes and assessment of physicians training to become infectious disease (ID) specialists in Europe in early 2024 and to document the provision of specialists, trainees and training centres in each country. METHODS:Delegates to the ID Section and Board of the European Union of Medical Specialists entered national data on a web-based survey tool in late 2023-early 2024. Results were compared with European Union of Medical Specialists recommendations on the structure and content of postgraduate training in ID in Europe (2018), and to results of a similar survey in early 2021. RESULTS:Responses were received from all 35 countries; 27/35 (77%) recognize ID as an independent speciality and 7/35 (20%) as a subspeciality. Spain does not officially recognize the speciality. In Cyprus, Iceland, and Luxembourg, despite official recognition of the sub-/speciality, ID training must be completed abroad. Paediatric ID was recognized in 16/35 (46%) countries. The number of adult ID specialists varied from 78.8 per million inhabitants in Sweden to 0.6 in Germany. Only 7/31 (23%) national programmes provide the minimum recommended 6 months of training in medical microbiology. Assessment methods included logbooks/portfolios in 25/31 (81%), final examinations in 25/31 (81%) and workplace-based assessments in 21/31 (68%). DISCUSSION:There has been little change since 2021 in speciality status or in structure and content of training programmes across Europe. There have been large increases in training position numbers in several countries, possibly in response to COVID-19. Continued low compliance with the 2018 recommendations to increase exposure to medical microbiology during training highlights the slow pace of change. Logistic barriers to change and to harmonization across Europe remain and are discussed in the context of published concerns of trainees.

Introduction. Strongyloides stercoralis, the human threadworm, is a parasitic nematode with global distribution, estimated to infect over 600 million people. Chronic infection is often asymptomatic, but hyperinfection and dissemination syndromes can occur in the immunosuppressed with high case fatality rates. Whilst strongyloidiasis is endemic in Fiji, its prevalence in Fijian migrant groups in the UK is unknown. Gap Statement. No previous studies have been conducted on the prevalence of Strongyloides and other gastrointestinal parasites (GIPs) in Fijian migrants to the UK. Aim. We conducted a cross-sectional study of the prevalence of GIPs in a Fijian migrant population. Methodology. Participants completed a questionnaire on residence, travel and clinical symptoms and were asked to provide a serum sample for S. stercoralis IgG ELISA, venous blood samples for eosinophil count and a faecal sample for charcoal culture, multiplex real-time PCR (rtPCR) and microscopy after formalin-ethyl acetate concentration. Sequencing was performed on pooled Strongyloides larvae for nuclear 18S rRNA hyper-variable regions (HVRs) I and IV. Results. A total of 250 participants (94% male) with median (range) age 37 (20-51) years entered the study, 15 (1-24) years since leaving Fiji. S. stercoralis IgG ELISA was positive in 87/248 (35.1 %) and 14/ 74 (18.9%) had a GIP detected in faeces. This included 7/ 74 (9.5 %) with Strongyloides and 5/74 (6.8%) with hookworms. Dermatological symptoms were more common in those with Strongyloides, and eosinophilia (> 0.5x109 cells per litre) was present in 55.6% of those with positive S. stercoralis IgG. rtPCR was the most sensitive faecal diagnostic test for Strongyloides and hookworms in faeces. Sequences of nuclear 18S rRNA for HVRs I and IV confirmed the presence of S. stercoralis. Conclusion. This first cross-sectional study in Fijian migrants found a high rate of chronic infection with GIPs, particularly S. stercoralis. Faecal microscopy was insensitive compared to charcoal culture, rtPCR or serology, demonstrating the importance of specialist parasitological tests when investigating people with a suspected chronic infection. Our study highlights an overlooked burden of strongyloidiasis in the UK and has implications for screening and treatment programmes in Fiji and for migrants from Fiji.

BACKGROUND:Gastrointestinal parasite (GIP) infections are a major cause of global morbidity, infecting hundreds of millions of people each year and potentially leading to lifelong infection and serious complications. Few data exist on screening for GIP infections in migrants entering the UK or on the current performance of different traditional diagnostic approaches. This study aimed to describe the prevalence of GIP infections in Nepalese Gurkha recruits screened on arrival in the UK. METHODOLOGY/PRINCIPAL FINDINGS:We present a retrospective analysis of data from screening male adults (18-21 years) who arrived in the UK from Nepal between 2012 and 2020. Three separate faecal samples were obtained from participants at weekly intervals and processed for formalin-ethyl acetate (FEA) concentration/light microscopy and charcoal culture. Serum samples were analysed for IgG antibodies to Strongyloides stercoralis by ELISA. Results were available from 2,263 participants, of whom 463 (20.5%, 95% CI 18.8%-22.2%) had a positive diagnostic test for at least one GIP infection. A total of 525 potential infections were identified. Giardia duodenalis was most common (231/2263, 10.2%), followed by S. stercoralis (102/2263, 4.5%), and hookworm species (86/2263, 3.8%). Analysis (microscopy and culture) of the initial stool sample diagnosed only 244/427 (57.1%) faecally identified pathogens, including 41/86 (47.7%) hookworm infections. The proportion of participants infected with any GIP showed a downward trend over the study period. Log-binomial regression showed risk of infection decreasing by 6.1% year-on-year (95% CI 3.2% - 9.0%). This was driven predominantly by a fall in hookworm, S. stercoralis and Trichuris trichiura prevalence. CONCLUSIONS/SIGNIFICANCE:The level of potentially pathogenic GIP infection in young Nepalese men migrating to the UK is high (20.5%) and requires a combined diagnostic approach including serology and analysis of multiple stool samples incorporating specialised parasitological methods. Advances in molecular approaches may optimise and simplify the intensive screening strategy required.

Objectives Encephalitis, brain inflammation and swelling, most often caused by an infection or the body’s immune defences, can have devastating consequences, especially if diagnosed late. We looked for clinical predictors of different types of encephalitis to help clinicians consider earlier treatment. Methods We conducted a multicentre prospective observational cohort study (ENCEPH-UK) of adults (> 16 years) with suspected encephalitis at 31 UK hospitals. We evaluated clinical features and investigated for infectious and autoimmune causes. Results 341 patients were enrolled between December 2012 and December 2015 and followed up for 12 months. 233 had encephalitis, of whom 65 (28%) had HSV, 38 (16%) had confirmed or probable autoimmune encephalitis, and 87 (37%) had no cause found. The median time from admission to 1st dose of aciclovir for those with HSV was 14 hours (IQR 5–50); time to 1st dose of immunosuppressant for the autoimmune group was 125 hours (IQR 45–250). Compared to non-HSV encephalitis, patients with HSV more often had fever, lower serum sodium and lacked a rash. Those with probable or confirmed autoimmune encephalitis were more likely to be female, have abnormal movements, normal serum sodium levels and a cerebrospinal fluid white cell count < 20 cells x106/L, but they were less likely to have a febrile illness. Conclusions Initiation of treatment for autoimmune encephalitis is delayed considerably compared with HSV encephalitis. Clinical features can help identify patients with autoimmune disease and could be used to initiate earlier presumptive therapy.

Objectives This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the effects of antibiotic treatment for travellers’ diarrhoea in relation to: illness duration; adverse effects; acquisition of multidrug‐resistant organisms.

Infections caused by Plasmodium falciparum, P. vivax, and P. malariae have decreased globally following the successful roll-out of malaria elimination strategies. However, there have been increasing reports of human P. knowlesi infections across Southeast Asia; in some areas, it is now the only malaria species reported in humans. This is driven by land use change, forcing the simian macaque hosts and the Anopheles mosquito vectors into closer contact with humans, coupled with the potential loss of cross-protective immunity in countries approaching the elimination of human malaria species. P. knowlesi usually causes asymptomatic or mild disease in children, but adults may experience disease resembling severe falciparum malaria. It remains a public health burden on the local health systems, especially the need for rapid diagnosis and treatment to prevent severe disease. Following the introduction of polymerase chain reaction-based diagnostic technologies, other simian malarias such as P. coatneyi, P. cynomolgi, P. inui, P. inui-like and P. simiovale have also been found to cause natural human disease that had not previously been recognised. Furthermore, the discovery of P. brasilianum and P. simium as causes of naturally acquired malaria in South America has highlighted the need to incorporate a One Health approach to malaria control. This article reviews the clinical and epidemiological features of these malarias.

Objectives: Many patients with meningitis have no aetiology identified leading to unnecessary antimicrobials and prolonged hospitalisation. We used viral capture sequencing to identify possible pathogenic viruses in adults with community-acquired meningitis. Methods: Cerebrospinal fluid (CSF) from 73 patients was tested by VirCapSeq-VERT, a probe set designed to capture viral targets using high throughput sequencing. Patients were categorised as suspected viral meningitis - CSF pleocytosis, no pathogen identified (n = 38), proven viral meningitis - CSF pleocytosis with a pathogen identified (n = 15) or not meningitis - no CSF pleocytosis (n = 20). Results: VirCapSeq-VERT detected virus in the CSF of 16/38 (42%) of those with suspected viral meningitis, including twelve individual viruses. A potentially clinically relevant virus was detected in 9/16 (56%). Unexpectedly Toscana virus, rotavirus and Saffold virus were detected and assessed to be potential causative agents. Conclusion: VirCapSeq-VERT increases the probability of detecting a virus. Using this agnostic approach we identified Toscana virus and, for the first time in adults, rotavirus and Saffold virus, as potential causative agents in adult meningitis. Further work is needed to determine the prevalence of atypical viral candidates as well as the clinical impact of using sequencing methods in real time. This knowledge can help to reduce antimicrobial use and hospitalisations leading to both patient and health system benefits. (C) 2022 The British Infection Association. Published by Elsevier Ltd. All rights reserved.

Objectives: To define the status of infectious diseases (ID) as an approved specialty in Europe; to enumerate the number of specialists (in general and in relation to the overall population) and specialist trainees and describe the content, delivery and evaluation of postgraduate training in ID in different countries. Methods: Structured web-based questionnaire surveys in March 2021 of responsible national authorities, specialist societies and individual country representatives to the Section of Infectious Diseases of the European Union for Medical Specialties. Descriptive analysis of quantitative and qualitative responses. Results: In responses received from 33/35 (94.3%) countries, ID is recognized as a specialty in 24 and as a subspecialty of general internal medicine (GIM) in eight, but it is not recognized in Spain. The number of ID specialists per country varies from <5 per million inhabitants to 78 per million inhabitants. Median length of training is 5 years (interquartile range 4.0-6.0 years) with variable amounts of preceding and/ or concurrent GIM. Only 21.2% of countries (7/33) provide the minimum recommended training of 6 months in microbiology and 30% cover competencies such as palliative care, team working and leadership, audit, and quality control. Training is monitored by personal logbook or e-portfolio in 75.8% (25/33) and assessed by final examinations in 69.7% (23/33) of countries, but yearly reviews with trainees only occur in 54.5% (18/33) of countries. Conclusions: There are substantial gaps in modernization of ID training in many countries to match current European training requirements. Joint training with clinical microbiology (CM) and in multidisciplinary team working should be extended. Training/monitoring trainers should find greater focus, together with regular feedback to trainees within many national training programmes. (C) 2021 The Authors. Published by Elsevier Ltd on behalf of European Society of Clinical Microbiology and Infectious Diseases.