Professional Documents
Culture Documents
15 December 2003
Methods
A retrospective survey of medical records of
patients who had undergone elective hip or
knee joint replacements between June 2001
and June 2002 at Concord Repatriation
General Hospital (a 550 bed teaching
hospital affiliated with the University of
Sydney), was undertaken. Each surgeon who
performed these operations had their own
documented protocol for antibiotic
Gentamicin
Overall, 44.3% (39/88) of patients received a
single dose of gentamicin in theatre as PAP
for operative catheterisation. However 10/39
patients given gentamicin did not have an
IDC. Only 5 of these patients were operated
on by one of the two surgeons (Table 2)
whose protocols called for gentamicin
administration irrespective of IDC status.
Figure 1 summarises the initial dose of
gentamicin given as PAP. Appropriateness of
dosing could not be assessed.
>80mg
120 - 180mg
10.20%
180mg
28.20%
Results
Cephalosporins
The -lactam antibiotic, cephalothin, was the
only first generation cephalosporin, provided
by pharmacy and hence used in PAP by all of
the surgeons surveyed, despite their
individual
protocols
recommending
cephazolin. Only one of the surgical
61.50%
Drainage devices
Patient Characteristics
Median age (range)
Sex
74 (18 - 90)
Cases
(%)
53
35
(60.2%)
(39.8%)
10 / 88
5/10
2/10
3/10
(11.3%)
83/ 88
(94.3%)
MRSA positive
0/ 83
(0%)
Male
Female
-lactam allergy
rash
anaphylaxis
not specified
MRSA Status
Operative details
Arthroplasty type
Primary
Revision #
Hip
Knee*
Total
(%)
28
11
42
7
70/88
18/88
(79.5%)
(20.4%)
Operation duration
Oral antibiotics
Median (range)
5/88
(5.6%)
Invasive devices
Cases
(%)
Drain tubes
87/88
(98%)
1 day
(1 - 3)
50/88
(56.8%)
Tourniquet application
3 days
(1 - 11)
DOSE AT
INDUCTION
DOSE POST- OP
DURATION
INDWELLING URINARY
CATHETER
cephazolin
1g
1g 8/24 IV
cephazolin
cephalexin
1g
1g 8/24 IV
500mg 6/24 orally
trimethoprim
cephalothin*
gentamicin*
1g
160mg
1g 6/24 IV
160mg daily IV
no prophylaxis recorded
cephazolin
1g
1g 8/24 IV
One day
gentamicin 80mg IV x1
cephazolin
gentamicin
or other antibiotic
1g
cephalothin
1g
Australian
Guidelines
cephalothin OR
cephazolin
2g
1g
8 doses
Single dose at induction
Repeat dose if operation > 3 hours
gentamicin 80mg IV x1
no prophylaxis recommended
Allergies
Two patients with a history suggestive of
type 1 hypersensitivity reaction to penicillin
were prescribed and administered
cephalothin as PAP.
Discussion
The surveyed antibiotic prophylaxis
protocols were directed at junior medical
staff who often lack the experience
necessary to make informed judgements
about antibiotic administration. Outdated
and ambiguous surgical protocols can be the
source of confusion and inconsistent
medical management of patients.
Drug allergies
MRSA status
None of the PAP surgical protocols made
specific recommendations for PAP in
patients colonised with MRSA. The recent
guidelines recommend the use of IV
vancomycin. Interestingly, screening for
MRSA colonisation in elective surgery (that
is, in patients without risk factors for MRSA
colonisation) did not yield any positive
cultures.
Conclusions
In short, compliance with the existing PAP
protocols was inconsistent and potentially
confusing for resident staff to follow at our
hospital. The PAP protocols promoted
longer duration of antibiotic use than
recommended; most guidelines were
ambiguous with respect to gentamicin use
and did not account for several important
patient and operative factors such as the
patients weight and renal function. The
Therapeutic Antibiotic guidelines are an
ideal frame-work on which to improve
existing PAP protocols. Such best-practice
guidelines, if adopted unit-wide, would
improve resident prescribing, and promote a
more rational and regimented approach to
antibiotic use.
References
1. Hill C. et al. Lancet 1981;1:795-796.
2. Espehaug B. et al. J Bone & Joint Surg
(British) 1997;79:590-595 .
3. Dettendofer M. et al. Infection
2002;30:164-167.
4. Antibiotic Guidelines Writing Group.
Therapeutic Guidelines: Antibiotic
Version 12. Melbourne: Therapeutic
Guidelines Ltd; 2003.
5. McEniery D.W. et al. Drugs
1987;34 (Suppl 2)216-239
6. Mauerhan D.R. et al. J Bone & Joint Surg
1994; 76:39-45
7. Muller A.A. et al. Clin Infect Dis
2003;36:971-8
8. Mickelson J.D. et al. NEJM
1988;319:321-326
9. Vogley H.C. et al. Reviews in Medical
Microbiology 2000;11:223-231
10. Gillespie W.J., Clin Infect Dis
1997;25:1310-1317
11. Friedman R.J. et al. Clin Ortho & Related
Research 1990;260:17-23
12. Cunha B.A. et al. Infection 1984;12:80-84
Correlating the detection of vanB genes in faeces to the presence of vancomycinresistant enterococci (VRE): interference by vanB-containing anaerobes
1,2
1,2
Depts of Infectious Diseases and Microbiology, Austin and Repatriation Medical Centre, Melbourne.
2
Dept of Medicine, University of Melbourne, Melbourne.
Introduction
VRE colonisation and infection is
increasingly common in Australian
hospitals. Acquired vancomycin resistance
in enterococci encoded by the vanB operon
explains the majority of VRE isolates, and
the vanB2 allele linked to a Tn1549-like
element appears to dominate.1,2
Recently, the presence of the vanB operon
has been described in organisms other than
enterococci. These organisms include
Streptococcus bovis isolated from a stool
swab and four unrelated anaerobic
organisms isolated from faecal samples.7,9
Three of these organisms were from the
genus Clostridium and the fourth from the
genus Eggerthella. In both reports, the
patients
were
undergoing
routine
surveillance for VRE.
Many multiplex PCR protocols and primer
sets have been developed for the detection
of van genes in pure isolates of enterococci
(reviewed in reference 4). Although
conventional culture methods for the
detection of VRE are sensitive, the time
required to isolate organisms takes 3-5 days.
More recently, PCR protocols have been
described for the direct detection of van
genes from clinical samples or enrichment
broth cultures.5,6,8 However, the presence of
vanB in non-VRE isolates could lead to an
unacceptably high false positive rate when
screening by PCR for VRE carriage.
In this study, we set out to assess the
sensitivity (and specificity) of three vanB
PCR protocols on three different enrichment
broth cultures of faeces to identify both
VRE carriage and vanB gene carriage in a
mixed culture. In a random sample of those
specimens that were VRE culture negative /
vanB PCR positive, attempts were made to
isolate the source of the vanB signal to
establish the impact vancomycin resistant
organisms, other than enterococci, might
have on the performance of a vanB PCR for
detection of VRE.
Methods
Three growth media (anaerobic brain heart
infusion broth, AnO2 BHI; aerobic brain
heart infusion broth, BHI; and enterococcosel broth, EB) were used to culture
faecal specimens from 59 well-characterised
Results
The sensitivity and specificity of vanB PCR
protocols for the detection of VRE in
enrichment broths were as follows:
BHI broth
Primer/ PCR
A: Stinear et
al 9
B: Bell et al1
C: Dutka-Malen et
al 3
References
1. Bell et al. J. Clin. Microbiol. 1998;36;21872190.
2. Berry et al. Abstract no. 22, 3rd Annual
Meeting of the Australian Society of
Antimicrobials, Sydney, Australia, 2002
3. Dutka-Malen et al. J. Clin. Microbiol.
1995;33: 24-27
AnO2BHI broth
EB broth
Sensitivity
Specificity
Sensitivity
Specificity
Sensitivity
Specificity
92%
49%
92%
43%
100%
51%
92%
60%
92%
45%
92%
83%
67%
96%
59%
94%
17%
100%
vanB-containing
anaerobes may cause
false positive results in
PCR-based detection of
VRE directly from faecal
specimens
Clostridiales were isolated from 5
specimens that were vanB PCR positive but
VRE
culture
negative.
Isolates
demonstrated the presence of the vanB
operon linked to a Tn1549 - like transposon.
Conclusions
The sensitivity of PCR detection of
vanB/VRE carriage directly from faecal
specimens is dependent on the primer set
and media used. Moreover, as the sensitivity
of the vanB PCR protocol increases, so the
specificity of the test for VRE decreases
with the primer/PCR protocol of Bell et al.,
providing the best balance of sensitivity and
specificity. Since carriage of vanB is not the
exclusive domain of enterococci, care
Introduction
Staphylococcus lugdunensis was first
described by Freney et al in 1988 and is now
widely accepted as a significant pathogen,
although there continues to be a problem of
low awareness of the organism among
clinicians and laboratory staff. It is a
coagulase negative staphylococcus that
more closely resembles S aureus in its
pathogenicity. It has been implicated in a
variety of infections including endocarditis,
septicaemia, breast abscesses, orthopaedic,
skin and soft tissue infections.
In 1999, NCCLS introduced an oxacillin
interpretive breakpoint for disc diffusion
testing of coagulase negative staphylococci
(CNS). However this breakpoint was
established primarily for S epidermidis and
may not be suitable for other CNS (eg S
lugdunensis)
Oxacillin susceptibility
testing of S lugdunensis
can be determined by MIC
testing on MHA with 2%
NaCl added using NCCLS
S aureus interpretive
breakpoints
OX MIC
Interpretation
mecA gene
> 12mm
??
> 4mg/L
??
RESISTANT
DETECTED
> 13mm
??
> 2mg/L
??
SUSCEPTIBLE
NOT DETECTED
OX MIC
Interpretation
mecA gene
> 17mm
??
> 0.5mg/L
??
RESISTANT
DETECTED
> 18mm
??
> 0.25mg/L
??
SUSCEPTIBLE
NOT DETECTED
Method
From March 1998 to February 2003, 70
clinical isolates of S lugdunensis were
Results
MecA / nuc gene PCR testing (n = 70)
All isolates were mecA and nuc gene
negative.
Kirby-Bauer Disc Diffusion testing (n = 70)
Using the CNS oxacillin interpretive
> 18mm = susceptible), only
breakpoint (??
3 isolates (4%) were classified as oxacillin
susceptible.
Discussion
The NCCLS CNS disc diffusion and MIC
oxacillin interpretive breakpoints were not
suitable for S lugdunensis.
Although the NCCLS S aureus disc
diffusion oxacillin interpretive breakpoint
was not reliable for S lugdunensis, the
NCCLS MIC interpretive breakpoint
correctly classified all isolates as oxacillin
susceptible.
Conclusions
Clinically significant CNS requiring
susceptibility testing should be fully
identified.
NCCLS CNS and S aureus disc diffusion
interpretive breakpoints for oxacillin are
not reliable for S lugdunensis.
Oxacillin susceptibility testing of S
lugdunensis can be determined by mecA
gene PCR or by MIC testing on Mueller
Hinton Agar with 2% NaCl added using
NCCLS S aureus interpretive breakpoints.
Acknowledgements
Dr Michelle Porter from the Womens and
Childrens Hospital and Dr Sue Benson
from St John of God Pathology for
supplying clinical isolates.
References
Freney J, Brun Y, Bes M et al. Staphylococcus
lugdunensis sp. nov. and Staphylococcus
schleiferi sp. nov., two species from human
clinical specimens. Int J Syst Bacteriol.
1988;38:168-172
Tee WS, Soh SY, Lin R, Loo LH.
Staphylococcus lugdunensis carrying the
mecA gene causes catheter-associated
bloodstream infection in premature neonate
J Clin Micro 2003;41:519-520
NCCLS. Performance Standards for
Antimicrobial Susceptibility Testing; Twelfth
Informational Supplement. NCCLS document
M100-S12, Jan 2002. Vol.22 No 1
NCCLS. Performance Standards for
Antimicrobial Susceptibility Testing; Ninth
Informational Supplement. NCCLS document
M100-S9, Jan 1999. Vol.19 No 1
NCCLS. Performance Standards for
Antimicrobial Susceptibility Testing; Eighth
Informational Supplement. NCCLS document
M100-S8, Jan 1998. Vol.18 No 1
Total
funding
$490,500
Ron Skurray
Melissa Brown
$451,750
Lesley Roy
Jonathan Carapetis
Graham Reynolds
Judy Simpson
Elisabeth Hodson
$367,725
Ron Skurray
Neville Firth
Stephen Kwong
$425,250
Shelley Walton
James McCarthy
Bart Carrie
Deborah Holt
$506,625
Nicholas Graves
Peter Collignon
Michael Whitby
Diana Battistuta
Frances Birrell
Tony Pettitt
$117,000
$267,750
Nigel Stocks
John Turnidge
Alan Crockett
Anthony Veale
$388,875
Roger Nation
Jian Li
John Turnidge
Kingsley Coulthard
Robert Milne
Craig Rayner
$262,125
$133,513
Investigators
Lay Title
Melissa Brown
Ron Skurray
Mark Turner
Craig Rayner
$3,411,113
TOTAL FUNDING
Picture Quiz
Figure 1
Figure 2
NEWSLETTER CONTRIBUTIONS
Submission of articles for possible publication or letters
to the editor should be sent to:
Dr Wendy Munckhof,
ASA Newsletter Editor,
Infection Management Services Southern Queensland,
Princess Alexandra Hospital,
Ipswich Rd, Woolloongabba,
Brisbane, QLD 4102
Telephone: (07) 3240 5920
Facsimile: (07) 3240 5540
Email: wendy_munckhof@health.qld.gov.au
ASA SUBSCRIPTIONS
Subscriptions should be sent to:
Geoffrey Coombs
ASA Treasurer
Dept. of Microbiology & Infectious Diseases,
Royal Perth Hospital
GPO Box X2213
Perth WA 6001
Telephone: (08) 9224 2446
Facsimile: (08) 9224 1989
Email:geoffrey.coombs@health.wa.gov.au
Reference
NCCLS Reference method for broth dilution antifungal susceptibility
testing of yeasts; approved standard - Second edition. NCLLS
document M27-A2 [Vol 22 No. 15 August 2002]. This replaces M27A [Vol. 17 No. 9].
Picture quiz and answers provided by David Ellis, Womens &
Childrens Hospital, Adelaide.
NSW
Westmead Hospital
St Vincents Hospital
Prince of Wales Hospital
St George Hospital
Nepean Hospital
Royal Prince Alfred Hospital
Concord Repatriation General Hospital
Wollongong & Port Kembla Hospital
Royal North Shore Hospital
John Hunter Hospital
Liverpool Hospital
New Childrens Hospital Westmead
VIC:
Alfred Hospital
Monash Medical Centre
Royal Childrens Hospital
Royal Womens Hospital
Western Hospital
Box Hill Hospital
Geelong Hospital
Royal Melbourne Hospital
St Vincents Hospital
Austin & Repatriation Medical Centre
QLD:
Toowoomba Hospital
Rockhampton Hospital
Senior Pharmacist, Centralised Intravenous Additive Services (CIVAS), Dept of Pharmacy, King Edward Memorial
Hospital for Women and Princess Margaret Hospital for Children, Womens and Childrens Health Service, Perth
2
Senior Pharmacist, Alternative Site Infusion Service (ASIS), Infection Management Service,
Princess Alexandra Hospital, Brisbane
STABILITY in
elastomeric devicesb
DRUG
DILUENT
STABILITY in syringesa
Aciclovir 500mg
NaCl 0.9%,
Water for injection (WFI)
Amikacin 2.5mg/mL
NaCl 0.9%
14 days refrigerated4,5,6
Amoxicillin 10-50mg/mL
NaCl 0.9%
WFI
Aztreonam 20mg/mL
WFI
NaCl 0.9%
7 days refrigerated11,12
14 days refrigerated,
30 days frozen13
Benzyl Penicillin 3g
Cefotaxime 100mg/mL
Sodium citrate 4%
WFI
14 days refrigerated14
7 days refrigerated. 3 months at -20C
plus 7 days refrigerated when thawed.
Once thawed, should not be refrozen10,16
7 days refrigerated15
10 days refrigerated.
30 days frozen plus 24hours
post thawing.13
Cefepime 100mg/mL
WFI
14 days refrigerated3
Cefoxitin 2g
Ceftazidime 100mg/mL
WFI
WFI
7 days refrigerated19
7 days refrigerated. 3 months at -20C
plus 7 days refrigerated when thawed.
Once thawed, should not be refrozen16,20
10 days refrigerated13
7 days refrigerated13
Ceftriaxone 100mg/mL
WFI
Cephazolin 1g
WFI
Dicloxacillin
Flucloxacillin 100mg/mL
WFI
WFI
Gentamicin 10mg/mL
Meropenem 50mg/mL
NaCl 0.9%
WFI
14 days refrigerated24
6 months at -60C25 48 hours
refrigerated25
Teicoplanin
WFI
Ticarcillin/Clavulanic
Acid 100mg/mL
WFI
7 days refrigerated3
Tobramycin
14 days refrigerated28
10 days refrigerated13
Vancomycin 5mg/mL
NaCl 0.9%
3 months refrigerated29
14 days refrigerated3
10 days refrigerated,
30 days frozen3
10 days refrigerated,
30 days frozen plus 24 hours
post thawing.13
10 days refrigerated13
4 days refrigerated plus 6
hours at room temperature26
References
1. Zhang YP, Trissel LA, Martinez JF, et
al. Stability of acyclovir sodium 1, 7,
and 10mg/mL in 5% dextrose injection
and 0.9% sodium chloride injection. Am
J Health-Syst Pharm 1998;55:574-577.
2. Gupta VD, Pramar Y, and Bethea C.
Stability of acyclovir sodium in
dextrose and sodium chloride injections.
J Clin Pharm Ther 1989; 14: 451-456.
3. Guidelines for the administration of
drugs using the Homepump /
Homepump Eclipse disposable
elastomeric infusion systems. Lake
Forest, CA: I-Flow Corporation; 1996.
4. Kaplan MA, Coppola WP, Nunning
BC, et al. Pharmaceutical properties and
stability of amikacin: part 1. Curr Ther
Res 1976;20:352-358.
5. Nunning BC and Granatek AP. Physical
compatibility and chemical stability of
amikacin sulfate in large-volume
parenteral solutions, part ii. Curr Ther
Res Clin Exp 1976;20:359-368.
6. Zbrozek AS, Marble DA, Bosso JA, et
al. Compatibility and stability of
clindamycin phosphate-aminoglycoside
combinations within polypropylene
syringes. Drug Intell Clin Pharm
1987:21:806-810.
7. Cook B, Hill SA, Lynn B. The stability
of amoxycillin sodium in intravenous
infusion fluids. J Clin Hosp Pharm
1982;7:245-250
8. Lynn B. The stability and administration
of intravenous penicillins. Br J Intraven
Ther 1981;2:22-39
9. Needle R, Sizer T (Eds). The CIVAS
Handbook - The Centralised
Intravenous Additive Services
Reference. The Pharmaceutical Press,
London, 1998.
10. Ahmed ST, Parkinson R. The stability
of drugs in pre-filled syringes:
flucloxacillin, ampicillin, cefuroxime,
cefotaxime, and ceftazidime. Hosp
Pharm Pract 1992;2:285-289.
ANTIMICROBIALS 2004
PROGRAM
Novotel Brighton-Le-Sands, Sydney
Thursday 26th - 28th February, 2004
Plenary Speakers
Steven J Projan
New Drug Development
Director of Antibacterial Research,
Wyeth-Ayerst Research,
New York, USA
Steve has co-written over 60 original
scientific papers and has several areas of
interest including antimicrobial chemotherapy and resistance, genomics, microbial pathogenesis, and biotechnology. In
recent years his research has included
investigating antibiotic resistance in
bacteria from magpies and rabbits from
west Wales; identifying compounds that
inhibit the last steps of cell wall
biosynthesis; and using genomics to
detect novel antibacterial targets and
drugs. Steve is an enthusiastic orator
who brings both optimism and a fresh
approach to the conquest against
antimicrobial resistance.
In the words of Steve Projan.
Steven J Projan, PhD (Columbia 1990,
Molecular Genetics) is widely known for
his dilettantish approach to bacterial
pathogenicity,
antimicrobial
drug
resistance and anti-infective drug
discovery. Since 1988 he has directed a
group of dedicated scientists in antibacterial drug discovery at Wyeth
Research in Pearl River, New York, who
clearly deserve better. Dr Projan
identified tigecycline (GAR-936) as a
potential clinical candidate in 1994 by
blind dumb luck and fortunate timing, he
hopes to parlay that success into a
lucrative career in drug discovery and
standup comedy.
John Perfect
Antifungal Developments
Director
of
the
Mycology
Interdisciplinary Research Unit,
Professor of Medicine and Associate
Professor of Microbiology,
Duke Medical Center, North Carolina,
USA
John has over 200 published papers in
peer-reviewed journals to his credit and
has also co-authored a book on
ASA Newsletter, December 2003
Ivan Bastian
Consultant,
ESBL Workshop
Extended spectrum beta-lactamases
(ESBLs) originally detected in
Klebsiella pneumoniae and Escherichia
coli are now being detected in other
species of Enterobacteriaceae and Gram
negative
glucose
nonfermenters
throughout the world. New types are
emerging such as CTX-M and plasmidborne AmpC beta-lactamases. What is
the epidemiology of ESBLs in Australia
and what are the clinical implications?
When should laboratories test for these
organisms and what methods should be
used?
The ESBL workshop will discuss these
and other issues including discussion on
what confirmatory molecular tests are
available for the diagnostic microbiology
Dates to remember
Deadline for abstract submission:
19th December 2003
Abstract notification:
31st December, 2003
Close of early bird registration:
19th December 2003
(persons submitting accepted abstracts
will be able to register at early bird rate)
Accommodation booking deadline:
16th January, 2004
11
PRELIMINARY PROGRAM
Antimicrobials 2004 SYDNEY 26 - 28 FEBRUARY 2004 Novotel, Brighton Beach, Sydney
THURSDAY
0900 - 1000
FRIDAY
SATURDAY
Plenary 1
Plenary 2
Plenary 3
Antifungal Developments
Steve Projan
John Perfect
Ivan Bastian
MORNING TEA
1000 - 1030
1030 - 1200
Symposium 1
Symposium 3
Symposium 5
(Ken Bradstock)
1200 - 1400
LUNCH
POSTERS (Authors in Attendance)
LUNCH
Pfizer Pharmaceuticals Symposium
LUNCH
POSTERS
POSTERS
1400 - 1530
Proffered Papers 1
Proffered Papers 2
(six speakers)
(Six speakers)
ESBL Workshop
Introduction: The Expanding Spectrum of the
Extended Spectrums (Jan Bell)
Clinical Impact of ESBLs (John Turnidge)
AFTERNOON TEA
1530 - 1600
1600 - 1730
Symposium 2
Symposium 4
Staphylococcal Infections -
Question Time
(John Mills)
Scedosporium/Fusarium/Penicillium/
Pharmacokinetic/Pharmacodynamic
Considerations (Craig Rayner)
1730 - 1830
AGM
1830 - 1930
Welcome Reception
1900 - 2330
Conference Dinner
12