No scalpel vasectomy: a cross-sectional study of knowledge, attitude and practice of gynaecologists

Background: In spite of no scalpel vasectomy (NSV) being cheaper and safer, female sterilisations account for the majority of sterilisations performed worldwide. Research has focussed more on the “demand” and less on the “provider” side. Gynaecologists can be front-runners for the cause of population control in India. Hence, authors decided to estimate the knowledge of gynaecologists, their attitude and prevalent practice of NSV.Methods: Cross-sectional study. Interviewer-administered questionnaire used for face-to-face data collection from gynecologists registered with the Pune Obstetric and Gynecological Society.Results: Out of 447 gynecologists, 158 (35.3%) were males and 289 (64.7%) females. Mean age was 46.3 years ± 12.1 years, (range 24-80 years). Only 14 (3.1%) were trained in performing NSV. Only a minority knew about type of anaesthesia used (1.8%) and number of accesses needed (48.1%) for NSV. Only 40.7% and 18.1% knew about time to resume sexual activity and number of ejaculations to be covered by additional contraceptives after NSV respectively. More than half [258 (57.7%)] were willing to undergo training in NSV. Among those unwilling for training, female and older gynecologists (≥40 years) significantly outnumbered male and younger gynecologists (76.5% Vs. 23.5%; p=0.000 and 78.8% Vs. 21.2% respectively; p=0.000). Majority (79.9%) referred a couple willing for NSV to surgeons or urologists or advised female sterilization (17%).Conclusions: Knowledge of gynecologists about NSV was inadequate. Minority were trained in performing NSV. Male and younger gynecologists were willing to undergo training in NSV. Most preferred practices were referring couples elsewhere or advising female sterilization

Requests for malaria prevention advice to Public Health England, Malaria Reference Laboratory: a retrospective observational study.

BACKGROUND: The Malaria Reference Laboratory (MRL) provides a specialist advisory service for complex queries from healthcare professionals. This study was conducted to examine the types of queries that general practitioners and nurses ask around malaria prophylaxis, to identify issues which are not obvious from existing easily available sources. METHODS: We reviewed all the faxed requests received over a period of 6 months at the MRL. RESULTS: There were a total of 608 queries (104 concerning children) relating to 450 travellers. 98% of requests were from general practice (GP or practice nurse). The most common enquiries were about travellers to multiple destinations (95/529, 17.96%), prolonged duration of travel (70/529, 13.23%), the immunosuppressed (38/529, 7.18%), potential drug interactions (69/529, 13.04%), pregnancy and conception (36, 6.81%). 79/529 queries related to patients with multiple conditions requiring expert advice from the MRL. 27% of the enquiries could have been answered by consulting the UK malaria prophylaxis guidelines available on the MRL site. CONCLUSION: Most queries where practitioners requested help were not easily answered with existing guidelines. Pregnancy and epilepsy are areas where guidance needs strengthening. Difficulties for practitioners were multifactorial, it would be difficult to address all scenarios in guidelines without making them unwieldy

Use of Nanopore Sequencing to Characterise the Genomic Architecture of Mobile Genetic Elements Encoding bla CTX-M-15 in Escherichia coli Causing Travellers' Diarrhoea

Increasing levels of antimicrobial resistance (AMR) have been documented in Escherichia coli causing travellers’ diarrhoea, particularly to the third-generation cephalosporins. Diarrhoeagenic E. coli (DEC) can act as a reservoir for the exchange of AMR genes between bacteria residing in the human gut, enabling them to survive and flourish through the selective pressures of antibiotic treatments. Using Oxford Nanopore Technology (ONT), we sequenced eight isolates of DEC from four patients’ specimens who had all recently returned to the United Kingdome from Pakistan. Sequencing yielded two DEC harbouring bla(CTX-M-15) per patient, all with different sequence types (ST) and belonging to five different pathotypes. The study aimed to determine whether bla(CTX-M-15) was located on the chromosome or plasmid and to characterise the drug-resistant regions to better understand the mechanisms of onward transmission of AMR determinants. Patients A and C both had one isolate where bla(CTX-M-15) was located on the plasmid (899037 & 623213, respectively) and one chromosomally encoded (899091 & 623214, respectively). In patient B, bla(CTX-M-15) was plasmid-encoded in both DEC isolates (786605 & 7883090), whereas in patient D, bla(CTX-M-15) was located on the chromosome in both DEC isolates (542093 & 542099). The two bla(CTX-M-15)-encoding plasmids associated with patient B were different although the bla(CTX-M-15)-encoding plasmid isolated from 788309 (IncFIB) exhibited high nucleotide similarity to the bla(CTX-M-15)-encoding plasmid isolated from 899037 (patient A). In the four isolates where bla(CTX-M-15) was chromosomally encoded, two isolates (899091 & 542099) shared the same insertion site. The bla(CTX-M-15) insertion site in isolate 623214 was described previously, whereas that of isolate 542093 was unique to this study. Analysis of Nanopore sequencing data enables us to characterise the genomic architecture of mobile genetic elements encoding AMR determinants. These data may contribute to a better understanding of persistence and onward transmission of AMR determinants in multidrug-resistant (MDR) E. coli causing gastrointestinal and extra-intestinal infections

Genomic surveillance detects Salmonella enterica serovar Paratyphi A harbouring blaCTX-M-15 from a traveller returning from Bangladesh

Whole genome sequencing (WGS) has been used routinely by Public Health England (PHE) for identification, surveillance and monitoring of resistance determinants in referred Salmonella isolates since 2015. We report the first identified case of extended-spectrum-β-lactamase (ESBL) Salmonella enterica serovar Paratyphi A (S. Paratyphi A) isolated from a traveller returning to England from Bangladesh in November 2017. The isolate (440915) was resistant to ciprofloxacin and harboured both the mobile element ISEcp9 -blaCTX-M-15-hp-tnpA and blaTEM-191, associated with ESBL production. Phenotypic resistance was subsequently confirmed by Antimicrobial Susceptibility Testing (AST). S. Paratyphi A 440915 harboured an IncI1 plasmid previously reported to encode ESBL elements in Enterobacteriaceae and recently described in a S. Typhi isolate from Bangladesh. Results from this study indicate the importance of monitoring imported drug resistance for typhoidal salmonellae as ceftriaxone is the first line antibiotic treatment for complicated enteric fever in England. We conclude that WGS provides a rapid, accurate method for surveillance of drug resistance genes in Salmonella, leading to the first reported case of ESBL producing S. Paratyphi A and continues to inform the national treatment guidelines for management of enteric fever

Clinical and public health implications of increasing notifications of LEE-negative Shiga toxin-producing Escherichia coli in England, 2014–2022

Introduction. Shiga toxin-producing Escherichia coli (STEC) belong to a diverse group of gastrointestinal pathogens. The pathogenic potential of STEC is enhanced by the presence of the pathogenicity island called the Locus of Enterocyte Effacement (LEE), including the intimin encoding gene eae. Gap statement. STEC serotypes O128:H2 (Clonal Complex [CC]25), O91:H14 (CC33), and O146:H21 (CC442) are consistently in the top five STEC serotypes isolated from patients reporting gastrointestinal symptoms in England. However, they are eae/LEE-negative and perceived to be a low risk to public health, and we know little about their microbiology and epidemiology. Aim. We analysed clinical outcomes and genome sequencing data linked to patients infected with LEE-negative STEC belonging to CC25 (O128:H2, O21:H2), CC33 (O91:H14) and, and CC442 (O146:H21, O174:H21) in England to assess the risk to public health. Results. There was an almost ten-fold increase between 2014 and 2022 in the detection of all STEC belonging to CC25, CC33 and CC442 (2014 n=38, 2022 n=336), and a total of 1417 cases. There was a higher proportion of female cases (55–70 %) and more adults than children, with patients aged between 20–40 and >70 most at risk across the different serotypes. Symptoms were consistent across the three dominant serotypes O91:H14 (CC33), O146:H21 (CC442) and O128:H2 (CC25) (diarrhoea >75 %; bloody diarrhoea 25–32 %; abdominal pain 64–72 %; nausea 37–45 %; vomiting 10–24 %; and fever 27–30 %). Phylogenetic analyses revealed multiple events of acquisition and loss of different stx-encoding prophage. Additional putative virulence genes were identified including iha, agn43 and subA. Conclusions. Continued monitoring and surveillance of LEE-negative STEC infections is essential due to the increasing burden of infectious intestinal disease, and the risk that highly pathogenic strains may emerge following acquisition of the Shiga toxin subtypes associated with the most severe clinical outcomes

WGS for surveillance of antimicrobial resistance:A pilot study to detect the prevalence and mechanism of resistance to azithromycin in a UK population of non-typhoidal Salmonella

Objectives: WGS and phenotypic methods were used to determine the prevalence of azithromycin resistance in Salmonella enterica isolates from the UK and to identify the underlying mechanisms of resistance.  Methods: WGS by Illumina HiSeq was carried out on 683 Salmonella spp. isolates. Known genes associated with azithromycin resistance were detected by WGS using a mapping-based approach. Macrolide resistance determinants were identified and the genomic context of these elements was assessed by various bioinformatics tools. Susceptibility testing was in accordance with EUCAST methodology (MIC ≤16 mg/L).  Results: Fifteen isolates of non-typhoidal Salmonella enterica belonging to serovars Salmonella Blockley, Salmonella Typhimurium, Salmonella Thompson, Salmonella Ridge and Salmonella Kentucky showed resistance or decreased susceptibility to azithromycin (from 6 to >16 mg/L) due to the presence of macrolide resistance genes mphA, mphB or mefB. These genes were either plasmid or chromosomally mediated. Azithromycin-resistant Salmonella Blockley isolates harboured a macrolide inactivation gene cluster, mphA-mrx-mphr(A), within a novel Salmonella azithromycin resistance genomic island (SARGI) determined by MinION sequencing. This is the first known chromosomally mediated mphA gene cluster described in salmonellae. Phylogenetic analysis and epidemiological information showed that mphA Salmonella Blockley isolates were not derived from a single epidemiologically related event. The azithromycin MICs of the 15 Salmonella spp. isolates showed that the presence of the mphA gene was associated with MIC ≥16 mg/L, while the presence of mefB or mphB was not.  Conclusions: Azithromycin resistance due to acquisition of known macrolide resistance genes was seen in four different Salmonella serovars and can be either plasmid-encoded or chromosomally encoded

Diversity of the Genomes and Neurotoxins of Strains of Clostridium botulinum Group I and Clostridium sporogenes Associated with Foodborne, Infant and Wound Botulism.

Clostridium botulinum Group I and Clostridium sporogenes are closely related bacteria responsible for foodborne, infant and wound botulism. A comparative genomic study with 556 highly diverse strains of C. botulinum Group I and C. sporogenes (including 417 newly sequenced strains) has been carried out to characterise the genetic diversity and spread of these bacteria and their neurotoxin genes. Core genome single-nucleotide polymorphism (SNP) analysis revealed two major lineages; C. botulinum Group I (most strains possessed botulinum neurotoxin gene(s) of types A, B and/or F) and C. sporogenes (some strains possessed a type B botulinum neurotoxin gene). Both lineages contained strains responsible for foodborne, infant and wound botulism. A new C. sporogenes cluster was identified that included five strains with a gene encoding botulinum neurotoxin sub-type B1. There was significant evidence of horizontal transfer of botulinum neurotoxin genes between distantly related bacteria. Population structure/diversity have been characterised, and novel associations discovered between whole genome lineage, botulinum neurotoxin sub-type variant, epidemiological links to foodborne, infant and wound botulism, and geographic origin. The impact of genomic and physiological variability on the botulism risk has been assessed. The genome sequences are a valuable resource for future research (e.g., pathogen biology, evolution of C. botulinum and its neurotoxin genes, improved pathogen detection and discrimination), and support enhanced risk assessments and the prevention of botulism

Audit of Helicobacter pylori Testing in Microbiology Laboratories in England: To Inform Compliance with NICE Guidance and the Feasibility of Routine Antimicrobial Resistance Surveillance.

Introduction. The National Institute for Health and Clinical Excellence (NICE) guidance recommends that dyspeptic patients are tested for Helicobacter pylori using a urea breath test, stool antigen test, or serology. Antibiotic resistance in H. pylori is globally increasing, but treatment in England is rarely guided by susceptibility testing or surveillance. Aims. To determine compliance of microbiology laboratories in England with NICE guidance and whether laboratories perform culture and antibiotic susceptibility testing (AST). Methods. In 2015, 170 accredited English microbiology laboratories were surveyed, by email. Results. 121/170 (71%) laboratories responded; 96% provided H. pylori testing (78% on site). 94% provided H. pylori diagnosis using stool antigen; only four provided serology as their noninvasive test; 3/4 of these encouraged urea breath tests in their acute trusts. Only 22/94 (23%) of the laboratories performed H. pylori cultures from gastric biopsies on site; 9/22 performed AST, but the vast majority processed less than one specimen/week. Conclusions. Only five laboratories in England do not comply with NICE guidance; these will need the guidance reinforced. National surveillance needs to be implemented; culture-based AST would need to be centralised. Moving forward, detection of resistance in H. pylori from stool specimens using molecular methods (PCR) needs to be explored