Pantoea abscess mimicking sarcoma in a HTLV-1-infected Indigenous Australian man: case report and literature review

Gram-negative bacteria of the genus Pantoea are emerging bacterial causes of diverse sporadic and outbreak-linked infections. Chronic Pantoea abscesses are unusual and may give rise to a differential diagnosis of malignancy. Foreign body retention and host immune defects may be risk factors for such chronic infections

Incipient empyema as an embolic complication of group A streptococcal septic arthritis in a patient with concomitant influenza B infection.

A 43-year-old healthy male presented with left ankle septic arthritis. Surgical specimens cultured Streptococcus pyogenes (group A Streptococcus, GAS) and IV benzylpenicillin was commenced. In the setting of coryzal symptoms, a chest radiograph and nasopharyngeal swab revealed a left-sided pleural effusion and influenza B infection, respectively. Persisting fevers, rising CRP, and increasing breathlessness led to repeat chest radiography showing a rapidly enlarging left-sided effusion. Following intercostal catheter insertion with intrapleural fibrinolytic therapy, 6 L of haemorrhagic fluid was drained leading to defervescence and clinical improvement. At follow-up 4 weeks later, he was asymptomatic with a normal chest radiograph. Similar to previous reported cases of GAS empyema, this case was associated with concurrent viral respiratory tract infection, but is unusual as it arose through haematogenous seeding from an extra-thoracic source. This case reminds clinicians to be aware of the strongly pyogenic nature of GAS and its significance as a potential cause of pleural infection, especially in patients with concomitant viral respiratory infections

Modelling the cost-effectiveness of pulse oximetry in primary care management of acute respiratory infection in rural northern Thailand

Objectives We aimed to determine the cost-effectiveness of supplementing standard care with pulse oximetry among children <5 years with acute respiratory infection (ARI) presenting to 32 primary care units in a rural district (total population 241,436) of Chiang Rai province, Thailand, and to assess the economic effects of extending pulse oximetry to older patients with ARI in this setting. Methods We performed a model-based cost-effectiveness analysis from a health systems perspective. Decision trees were constructed for three patient categories (children <5 years, children 5–14 years, and adults), with a 1-year time horizon. Model parameters were based on data from 49,958 patients included in a review of acute infection management in the 32 primary care units, published studies, and procurement price lists. Parameters were varied in deterministic sensitivity analyses. Costs were expressed in 2021 US dollars with a willingness-to-pay threshold per DALY averted of 8624 US dollars. Results The annual direct cost of pulse oximetry, associated staff, training, and monitoring was 24,243 US dollars. It reduced deaths from severe lower respiratory tract infections in children <5 years by 0.19 per 100,000 patients annually. In our population of 14,075 children <5 years, this was equivalent to 2.0 DALYs averted per year. When downstream costs such as those related to hospitalisation and inappropriate antibiotic prescription were considered, pulse oximetry dominated standard care, saving 12,757 US dollars annually. This intervention yielded smaller mortality gains in older patients but resulted in further cost savings, primarily by reducing inappropriate antibiotic prescriptions in these age groups. The dominance of the intervention was also demonstrated in all sensitivity analyses. Conclusions Pulse oximetry is a life-saving, cost-effective adjunct in ARI primary care management in rural northern Thailand. This finding is likely to be generalisable to neighbouring countries with similar disease epidemiology and health systems

Perceptions and priorities for the development of multiplex rapid diagnostic tests for acute non-malarial fever in rural South and Southeast Asia: an international modified e-Delphi survey

Background Fever is a common presenting symptom in low- and middle-income countries (LMICs). It was previously assumed that malaria was the cause in such patients, but its incidence has declined rapidly. The urgent need to develop point-of-care tests for the most important causes of non-malarial acute febrile illness is hampered by the lack of robust epidemiological data. We sought to obtain expert consensus on analytes which should be prioritized for inclusion in fingerprick blood-based multiplex lateral flow rapid diagnostic tests (LF-RDTs) targeted towards four categories of patients with acute non-malarial fever in South and Southeast Asian LMICs, stratified by age (paediatric vs. adult) and care setting (primary vs. secondary care). Methodology/Principal findings We conducted a two-round modified e-Delphi survey. A total of 84 panellists were invited, consisting of seven each from 12 countries, divided into three regional panels (Mainland Southeast Asia, Maritime Southeast Asia, and South Asia). Panellists were asked to rank their top seven analytes for inclusion in LF-RDTs to be used in each patient category, justify their choices, and indicate whether such LF-RDTs should be incorporated into algorithm-based clinical decision support tools. Thirty-six panellists (43%) participated in the first round and 44 (52%) in the second. There was consensus that such LF-RDTs should be incorporated into clinical decision support tools. At a minimum, these LF-RDTs should be able to diagnose dengue and enteric fever in all patient categories. There was a clear preference to develop LF-RDTs for pathogens not readily detected by existing technologies, and for direct diagnosis through antigen detection. Pathogen biomarkers were prioritized over host inflammatory biomarkers, with CRP being the only one ranked consistently highly. Conclusions/Significance Our results provide guidance on prioritizing analytes for inclusion in context-specific multiplex LF-RDTs and similar platforms for non-malarial acute febrile illness, for which there is an urgent unmet need

Cost-effectiveness analysis of a multiplex lateral flow rapid diagnostic test for acute non-malarial febrile illness in rural Cambodia and Bangladesh

Background Multiplex lateral flow rapid diagnostic tests (LF-RDTs) may aid management of patients with acute non-malarial febrile illness (NMFI) in rural south and southeast Asia. We aimed to evaluate the cost-effectiveness in Cambodia and Bangladesh of a putative, as-yet-undeveloped LF-RDT capable of diagnosing enteric fever and dengue, as well as measuring C-reactive protein (CRP) to guide antibiotic prescription, in primary care patients with acute NMFI. Methods A country-specific decision tree model-based cost-effectiveness analysis was conducted from a health system plus limited societal perspective considering the cost of antimicrobial resistance. Parameters were based on data from a large observational study on the regional epidemiology of acute febrile illness, published studies, and procurement price lists. Costs were expressed in US dollars (value in 2022), and cost-effectiveness evaluated by comparing incremental cost-effectiveness ratios with conservative opportunity cost-based willingness-to-pay thresholds and the more widely used threshold of per capita gross domestic product (GDP). Findings Compared to standard of care, LF-RDT-augmented clinical assessment was dominant in Cambodia, being more effective and cost-saving. The cost per disability-adjusted life year (DALY) averted in Bangladesh was 482 US dollars , slightly above the conservative opportunity cost-based willingness-to-pay threshold of 388 US dollars and considerably lower than the GDP-based threshold of 2687 US dollars . The intervention remained dominant in Cambodia and well below the GDP-based threshold in Bangladesh when antimicrobial resistance costs were disregarded. Interpretation These findings provide guidance for academic, industry, and policymaker stakeholders involved in acute NMFI diagnostics. While definitive conclusions cannot be made in the absence of established thresholds, our results suggest that similar results are highly likely in some target settings and possible in others. Funding Wellcome Trust, UK Government, Royal Australasian College of Physicians, and Rotary Foundation

Severe rhabdomyolysis associated with RSV

Severe rhabdomyolysis is associated with morbidity and mortality. We report on a previously well male who developed severe rhabdomyolysis, sepsis, and multi-organ failure. The patient made a complete recovery. Extensive microbiological testing was only positive for RSV, making this the first reported case of adult RSV-related rhabdomyolysis in the literature

Antimicrobial prescribing and outcomes of community-acquired pneumonia in Australian hospitalized patients: a cross-sectional study

Objective: We aimed to assess prescribing practices, compliance with guidelines, and outcomes for patients who were admitted to the authors’ institution with community-acquired pneumonia (CAP). Methods: We performed a single-center retrospective cross-sectional study of adults with CAP presenting during the 2019 influenza season. CAP severity was assessed using the CURB-65 risk score. The effect of CURB-65 risk score use on the rate of appropriate antimicrobial prescribing was assessed using the chi-square test and reported as odds ratio (OR). Fisher’s exact test was used to assess the relationship between prescribing appropriateness and patient outcomes. Results: Patients with low-risk CAP were most likely to be inappropriately prescribed antimicrobials (OR: 4.77; 95% confidence interval: 2.44–10.47). In low-risk CAP, the most common prescribing error was overuse of ceftriaxone. In high-risk CAP, the most common errors were ceftriaxone underdosing and missed atypical coverage with azithromycin. Overall, 80% of patients were considered to have been inappropriately prescribed antimicrobials. No effect on mortality was observed. Conclusions: In this study, we found low use of CAP risk scores and low adherence to antimicrobial prescribing guidelines for CAP at the authors’ institution

Prospects for the development of community-based care in remote rural areas: a stakeholder analysis in Laos

Background Community-based health programmes have been a cornerstone of primary care in Laos for decades. The study presented here aimed to document prospects for the development of current programmes, considering perceptions about health and health care priorities in the communities, implementation challenges, the policy landscape and opportunities associated with the availability of new technologies. Methods The research design primarily involved qualitative in-depth interviews with stakeholders (n = 35) responsible for the planning, management, or implementation of community-based care in Laos at different levels of the health system. These included health managers at central departments or institutes of the Ministry of Health, provincial health departments, district health offices, heads of health centres, village health volunteers, community representatives, and international stakeholders. Results There was consensus that service delivery is still a challenge in many areas, due to geographic inaccessibility of health facilities, communication barriers, health-seeking behaviour, trust, and gender discrimination, particularly among ethnic minorities. In these settings, community health workers have the potential to extend the reach of the formal health system, acting as cultural brokers across sectors of society, ethnicities, and worldviews. To maximise impact, planners need to carefully consider the implementation model, financing arrangements, health system integration, and changing health priorities in the communities. Conclusions This study examined challenges to, and opportunities for, the expansion and health system integration of community-based care in Laos. Further development and horizontal integration of community-based care remains a complex financing and governance challenge, although the renewed emphasis on primary care and the ongoing process of decentralisation provide a favourable policy environment in the country to sustain and potentially expand existing programmes