Data collection and its completeness.

<p>Data collection and its completeness.</p

A Novel Clinical Grading Scale to Guide the Management of Crusted Scabies

<div><p>Background</p><p>Crusted scabies, or hyperinfestation with <i>Sarcoptes scabiei</i>, occurs in people with an inadequate immune response to the mite. In recent decades, data have emerged suggesting that treatment of crusted scabies with oral ivermectin combined with topical agents leads to lower mortality, but there are no generally accepted tools for describing disease severity. Here, we describe a clinical grading scale for crusted scabies and its utility in real world practice.</p><p>Methodology/Principal Findings</p><p>In 2002, Royal Darwin Hospital (RDH), a hospital in tropical Australia developed and began using a clinical grading scale to guide the treatment of crusted scabies. We conducted a retrospective observational study including all episodes of admission to RDH for crusted scabies during the period October 2002–December 2010 inclusive. Patients who were managed according to the grading scale were compared with those in whom the scale was not used at the time of admission but was calculated retrospectively. There were 49 admissions in 30 patients during the study period, of which 49 (100%) were in Indigenous Australians, 29 (59%) were male and the median age was 44.1 years. According to the grading scale, 8 (16%) episodes were mild, 24 (49%) were moderate, and 17 (35%) were severe. Readmission within the study period was significantly more likely with increasing disease severity, with an odds ratio (95% CI) of 12.8 (1.3–130) for severe disease compared with mild. The patients managed according to the grading scale (29 episodes) did not differ from those who were not (20 episodes), but they received fewer doses of ivermectin and had a shorter length of stay (11 vs. 16 days, p = 0.02). Despite this the outcomes were no different, with no deaths in either group and a similar readmission rate.</p><p>Conclusions/Significance</p><p>Our grading scale is a useful tool for the assessment and management of crusted scabies.</p></div

Disease risk factors and their relationship with mortality.

<p>Disease risk factors and their relationship with mortality.</p

Cases of disease recurrence with potential explanations.

<p>Cases of disease recurrence with potential explanations.</p

Disease severity, outcome and supportive care over the course of the study.

<p>Disease severity, outcome and supportive care over the course of the study.</p

Age at presentation and case-fatality rate.

<p>Age at presentation and case-fatality rate.</p

The presence of risk factors for disease, stratified by ATSI status.

<p>The presence of risk factors for disease, stratified by ATSI status.</p

Demographics and comorbidities.

a<p>Median [IQR].</p

Intravenous Therapy Duration and Outcomes in Melioidosis: A New Treatment Paradigm

<div><p>Background</p><p>International melioidosis treatment guidelines recommend a minimum 10 to 14 days’ intravenous antibiotic therapy (intensive phase), followed by 3 to 6 months’ oral therapy (eradication phase). This approach is associated with rates of relapse, defined as recurrence following the eradication phase, that can exceed 5%. Rates of recrudescence, defined as recurrence during the eradication phase, have not previously been reported. In response to low eradication phase completion rates in Australia, a local guideline has evolved over the last ten years recommending a longer minimum intensive phase duration for many cases of melioidosis.</p><p>Methodology/ Principal Findings</p><p>This retrospective cohort study reviews antibiotic duration for the first episode of care for all patients diagnosed with melioidosis and surviving the intensive phase during a recent three year period in the tropical north of Australia’s Northern Territory; we also review adherence to the current local guideline and treatment outcomes. Of 215 first episodes of melioidosis surviving the intensive phase, the median (interquartile range) intensive phase duration was 26 (14-34) days. One hundred and eight (50.2%) patients completed eradication therapy; 58 (27.0%) patients took no eradication therapy. At 28 months’ follow-up, one (0.5%) relapse and eleven (5.1%) recrudescences had occurred. On exact logistic regression analysis, the only independent risk factors for recrudescence were self-discharge during the intensive phase (odds ratio 6.2 [95% confidence interval 1.2-30.0]) and septic shock (odds ratio 5.3 [95% confidence interval 1.1-25.7]).</p><p>Conclusions/ Significance</p><p>Relapsed melioidosis is rare in patients who receive a minimum intensive phase duration specified by our guideline and extended according to clinical progress. Recrudescence rates may improve with reductions in rates of self-discharge. Given the low relapse rate despite a high rate of eradication therapy non-adherence, the duration and necessity of eradication therapy for different patients after guideline-concordant intensive therapy should be evaluated further.</p></div

Grading scale, disease severity, and outcomes.

a<p>n(%).</p>b<p>Highest plasma C-reactive protein during the hospital admission (median [IQR]).</p>c<p>Lowest serum albumin value during the hospital admission (median [IQR]).</p>d<p>P value for moderate and severe combined, compared with mild, except where indicated.</p>e<p>Median [IQR].</p>f<p>P value based on Kruskall Wallis test comparing the three groups.</p