Identification of Staphylococci by Polymerase Chain Reaction Directly from a Positive Blood Culture and Effect on Patient Care

Background: As one of the most common bloodstream infections worldwide, Staphylococcus aureus bacteremia places a major burden on health care. Implementation of a rapid, genetic-based diagnostic test may have important implications in the clinical management of patients with S. aureus bacteremia. Objectives: The primary objective was to assess concordance between testing based on polymerase chain reaction (PCR) and the current gold standard, culture and sensitivity testing; the secondary objective was to assess the impact of this technology on patient care. Methods: A pre–post intervention retrospective chart review was used to document the hospital course of patients with a diagnosis of S. aureus bacteremia before and after implementation of the PCR-based diagnostic system. Laboratory results from all patient samples subjected to PCR-based analysis following implementation of this system were compared with culture and sensitivity data for the same samples to determine accuracy of the new system. In addition, time to optimal therapy for each patient was calculated as the interval between the initiation of empiric and terminal therapies. The appropriateness of antimicrobial treatment was characterized as guideline-concordant, nonconcordant with the guidelines, or nonconcordant yet still clinically appropriate. Results: In total, 98 and 99 patients met the inclusion criteria before and after implementation of the PCR-based diagnostic system, respectively. PCR-based results displayed 99.8% concordance (440/441 total samples) with results from culture and sensitivity testing. The time to optimal therapy was significantly shorter after implementation, by a mean of 22.8 h (p < 0.001). Overall, 97% of empiric and 99% of terminal antimicrobial regimens were either guideline-concordant or clinically appropriate for treatment of S. aureus bacteremia; 3% of empiric and 1% of terminal antimicrobial regimens were nonconcordant with clinical guidelines without any explanation based on other clinical considerations. Conclusions: The study findings support the utility of using a direct-from-positive-blood-culture PCR-based diagnostic tool as the primary method of identifying S. aureus bacteremia in patients, as well as the acceptance of and acting upon the new assay’s results by our local clinicians. PCR-based assays can help reduce the time to optimal terminal therapy for patients with bacteremia.  RÉSUMÉ Contexte : La bactériémie à Staphylococcus aureus (BAC-SA), qui est l’une des infections du sang les plus répandues dans le monde, fait peser une lourde charge sur les soins de santé. La mise en place d’un test diagnostique génétique rapide pourrait avoir des retombées importantes sur la gestion clinique des patients présentant une BAC-SA. Objectifs : L’objectif principal consistait à évaluer la concordance entre les tests basés sur la réaction en chaîne par polymérase (PCR) et le test de sensibilité et de culture, qui est la référence absolue actuelle; l’objectif secondaire consistait à évaluer l’impact de cette technologie sur les soins des patients. Méthodes : Un examen rétrospectif des dossiers pré- et post-intervention a servi à décrire le séjour à l’hôpital des patients ayant reçu un diagnostic de BAC-SA avant et après la mise en place du système de diagnostic de la PCR. Les résultats de laboratoire de tous les échantillons des patients soumis à une analyse de la PCR à la suite de la mise en place de ce système ont été comparés avec les données relatives à la culture et à la sensibilité de ces mêmes échantillons afin de déterminer la précision du nouveau système. De plus, l’évaluation du délai d’atteinte du traitement optimal de chaque patient repose sur le calcul de l’intervalle entre le début des thérapies empiriques et terminales. La pertinence du traitement antimicrobien était caractérisée comme suit : concordance avec les lignes directrices, non-concordance avec les lignes directrices ou non-concordance mais encore approprié d’un point de vue clinique. Résultats : Au total, 98 et 99 patients ont satisfait au critère d’inclusion respectivement avant et après la mise en place du système de diagnostic de la PCR. Les résultats basés sur la PCR affichaient une concordance de 99,8 % (440/441 échantillons au total) avec les résultats des tests de sensibilité et de culture. La diminution du délai d’atteinte du traitement optimal était importante après la mise en place du système, puisqu’elle atteignait en moyenne 22,8 h (p < 0,001). De manière générale, 97 % des régimes antimicrobiens empiriques et 99 % des régimes antimicrobiens terminaux concordaient avec les lignes directrices ou étaient cliniquement appropriés pour le traitement de la BAC-SA; 3 % des régimes antimicrobiens empiriques et 1 % des régimes antimicrobiens terminaux n’étaient pas conformes aux lignes directrices cliniques sans qu’aucune explication basée sur d’autres considérations cliniques n’ait été donnée. Conclusions : Les résultats de l’étude confirment la nécessité d’utiliser un outil diagnostique basé sur la PCR directement de l’hémoculture positive en guise de méthode principale pour déterminer la présence de BAC-SA chez les patients ainsi que l’acceptation et l’utilisation des nouveaux résultats du test par nos cliniciens locaux. Les tests basés sur la PCR peuvent aider à réduire le délai d’attente du traitement optimal pour les patients atteints de BAC-SA.

Development of a Patient-Oriented Intervention to Support Patient-Provider Conversations about Unnecessary Lower Back Pain Imaging

Background: despite the efforts of multiple stakeholders to promote appropriate care throughout the healthcare system, studies show that two out of three lower back pain (LBP) patients expect to receive imaging. We used the Choosing Wisely Canada patient-oriented framework, prioritizing patient engagement, to develop an intervention that addresses lower back pain imaging overuse. Methods: to develop this intervention, we collaborated with a multidisciplinary advisory team, including two patient partners with lower back pain, researchers, clinicians, healthcare administrators, and the Choosing Wisely Canada lead for Saskatchewan. For this qualitative study, data were collected through two advisory team meetings, two individual interviews with lower back pain patient partners, and three focus groups with lower back pain patient participants. A lower back pain prescription pad was developed as an outcome of these consultations. Results: participants reported a lack of interactive and informative communication was a significant barrier to receiving appropriate care. The most cited content information for inclusion in this intervention was treatments known to work, including physical activity, useful equipment, and reliable sources of educational material. Participants also suggested it was important that benefits and risks of imaging were explained on the pad. Three key themes derived from the data were also used to guide development of the intervention: (a) the role of imaging in LBP diagnosis; (b) the impact of the patient-physician relationship on LBP diagnosis and treatment; and (c) the lack of patient awareness of Choosing Wisely Canada and their recommendations. Conclusions: the lower back pain patient-developed prescription pad may help patients and clinicians engage in informed conversations and shared decision making that could support reduce unnecessary lower back pain imaging

Crop Updates 2006 - Geraldton

This session covers twenty six papers from different authors 2006 Seasonal Outlook, David Stephens and Michael Meuleners, Department of Agriculture 2006 Wheat Market Outlook, Tony Smith, Plum Grove Commodity Trading Solutions Will Budgets Change in 2006? Peter Tozer, Department of Agriculture Wheat varieties – what does the industry need and how do we get closer? David Bowran Department of Agriculture Performance of Wheat Varieties in National Variety Testing (NVT) WA, Peter Burges, Agritech Crop Research Survey of lupin root health (in major production areas), Geoff Thomas, Bill MacLeod, Ken Adcock, Katie Bell, Ciara Beard and Anne Smith, Department of Agriculture Managing root disease under intensive cropping, Bill MacLeod, and Vivien Vanstone, Department of Agriculture Investigation into the adequacy OF SEALED FARM SILOS IN Western Australia to control phosphine-resistant Rhyzopertha dominica, C.R. Newman, Department of Agriculture Phosure – Extending the Life of Phosphine, Gabrielle Coupland and Ern Kostos, Cooperative Bulk Handling IWM performs over 5 years in 33 focus paddocks, Peter Newman and Glenn Adam, Department of Agriculture Maintaining wheat and lupin yields using phase pastures and shielded sprayers to manage increasing herbicide resistance, Caroline Peek, Nadine Eva, Chris Carter and Megan Abrahams, Department of Agriculture Can sheep selectively graze weeds out of crops? A model for using sheep rather than chemicals, Tim Wiley, Department of Agriculture and Dean Revell, CSIRO Livestock Environmental Protection (Clearing of Native Vegetation) Regulations 2004, Anne Finlay, Department of Environment What lies beneath? – Understanding constraints to productivity below the soil surface, Stephen Davies and Chris Gazey, Department of Agriculture, Bob Gilkes, Dan Evans and Tania Liaghati, University of Western Australia Phoma blight (P. schneiderae), a risk for WA lupins? Geoff Thomas and Mark Sweetingham, Department of Agriculture The 2005 Wheat streak mosaic virus epidemic in New South Wales and the threat posed to the Western Australian wheat industry, Roger Jones and Nichole Burges, Department of Agriculture Zone Management for fun and Profit, Department of Agriculture, Tony Rosser and Owen Mann, Great Northern Rural Annual Ryegrass Toxicity (ARGT) – How to manage the Risk, Marnie Thomas, Department of Agriculture The future of lupin varieties, Wayne Parker, Department of Agriculture Analysis of a wheat-pasture rotation in the 330mm annual rainfall zone using the STEP model, Andrew Blake and Caroline Peek, Department of Agriculture Value Added Opportunities for Lupins in High Value Feed and Food Markets, Jason Craig and Mark Tucek, Cooperative Bulk Handling An overview of the potential for a Biofuels Industry in Western Australia, Anne Wilkins and Nathan Hancock, Department of Agriculture The GMO Picture – a Reality Check, Dr Sue Sutherland, Department of Agriculture Nitrogen applied in splits rather than all applied at seeding returns higher gross income from wheat cropped on a leaching sandy soil at Muresk (Central agricultural region), Darshan Sharma, Department of Agriculture and Lionel Martin, Muresk Institute, Curtin University of Technology Potassium response in cereal cropping within the medium rainfall central wheatbelt, Jeff Russell, Department of Agriculture, Angie Roe and James Eyres Farm Focus consultants Western Region Barley Variety Guide2006, Alaina Smith, Blakely Paynter and Andrea Hills, Department of Agricultur

Hybridisation of Australian chickpea cultivars with wild Cicer spp. increases resistance to root-lesion nematodes (Pratylenchus thornei and P. neglectus)

Australian and international chickpea (Cicer arietinum) cultivars and germplasm accessions, and wild annual Cicer spp. in the primary and secondary gene pools, were assessed in glasshouse experiments for levels of resistance to the root-lesion nematodes Pratylenchus thornei and P. neglectus. Lines were grown in replicated experiments in pasteurised soil inoculated with a pure culture of either P. thornei or P. neglectus and the population density of the nematodes in the soil plus roots after 16 weeks growth was used as a measure of resistance. Combined statistical analyses of experiments (nine for P. thornei and four for P. neglectus) were conducted and genotypes were assessed using best linear unbiased predictions. Australian and international chickpea cultivars possessed a similar range of susceptibilities through to partial resistance. Wild relatives from both the primary (C. reticulatum and C. echinospermum) and secondary (C. bijugum) gene pools of chickpea were generally more resistant than commercial chickpea cultivars to either P. thornei or P. neglectus or both. Wild relatives of chickpea have probably evolved to have resistance to endemic root-lesion nematodes whereas modern chickpea cultivars constitute a narrower gene pool with respect to nematode resistance. Resistant accessions of C. reticulatum and C. echinospermum were crossed and topcrossed with desi chickpea cultivars and resistant F 4 lines were obtained. Development of commercial cultivars with the high levels of resistance to P. thornei and P. neglectus in these hybrids will be most valuable for areas of the Australian grain region and other parts of the world where alternating chickpea and wheat crops are the preferred rotatio