Objective We describe cases of invasive group A Streptococcus (iGAS) in mothers or neonates and assess management according to national guidelines, which recommend administering antibiotics to both mother and neonate if either develops iGAS infection within 28 days of birth and investigation of clusters in maternity units.Design Cross-sectional retrospective study. Setting and population Notified confirmed iGAS cases in either mothers or neonates with onset within 28 days of birth in London and the South East of England between 2010 and 2016Method Review of public health records of notified cases.Main outcome measures Incidence and onset time of iGAS in postpartum mothers and babies, proportion given prophylaxis, maternity unit clusters within 6 months.Results We identified 134 maternal and 21 neonatal confirmed iGAS infections. The incidence (in 100 000 person years) of iGAS in women within 28 days postpartum was 109 (95% CI 90-127) compared with 1.3 in other females aged 15-44. For neonates the incidence was 1.5 (95% CI 9-23). The median onset time was 2 days postpartum [interquartile range (IQR) 0-5 days] for mothers and 12 days (IQR 7-15 days) for neonates. All eligible mothers and most (109, 89%) eligible neonates received chemoprophylaxis. Of 20 clusters (59 cases of GAS and iGAS) in maternity units, two clusters involved possible transmission. However, in 6 of 15 clusters, GAS isolates were not saved for comparison even after relevant guidance was issued.Conclusions iGAS infection remains a potential postpartum risk. Prophylaxis among neonates and storage of isolates from maternity cases can be improved.
Open-water swimming is increasingly popular, often in water not considered safe for bathing. Limited evidence exists on the associated health risks. We investigated gastrointestinal illness in 1100 swimmers in a River Thames event in London, UK, to describe the outbreak and identify risk factors. We conducted a retrospective cohort study. Our case definition was swimmers with any: diarrhoea, vomiting, abdominal cramps lasting ⩾48 h, nausea lasting ⩾48 h, with onset within 9 days after the event. We used an online survey to collect information on symptoms, demographics, pre- and post-swim behaviours and open-water experience. We tested associations using robust Poisson regression. We followed up case microbiological results. Survey response was 61%, and attack rate 53% (338 cases). Median incubation period was 34 h and median symptom duration 4 days. Five cases had confirmed microbiological diagnoses (four Giardia, one Cryptosporidium). Wearing a wetsuit [adjusted relative risk (aRR) 6·96, 95% confidence interval (CI) 1·04-46·72] and swallowing water (aRR 1·42, 95% CI 1·03-1·97) were risk factors. Recent river-swimming (aRR 0·78, 95% CI 0·67-0·92) and age >40 years (aRR 0·83, 95% CI 0·70-0·98) were protective. Action to reduce risk of illness in future events is recommended, including clarification of oversight arrangements for future swims to ensure appropriate risk assessment and advice is provided.
Invasive group A streptococcal (iGAS) infections cause severe disease and death, especially in residents of long-term care facilities (LTCFs). In order to inform iGAS prevention, we compared the risk of iGAS in LTCF residents and community residents. We identified LTCF residents among cases of iGAS from national surveillance (2009-2010) using postcode matching, and cases of hospital-acquired infections via hospital admission records. We used Poisson regression to calculate incidence rate ratios (IRR) and logistic regression to explore factors associated with case fatality rate (CFR). A total of 2741 laboratory-confirmed iGAS cases were matched to a hospital admission: 156 (6%) were defined as hospital-acquired. Out of the total cases, 96 (3·5%) were LTCF residents. Compared with community residents, LTCF residents over 75 years of age had a higher risk of iGAS infection (IRR = 1·7; 95% CI 1·3-2·1) and CFR (OR = 2·3; 95% CI 1·3-3·8). Amongst community-acquired cases, the risk of iGAS in LTCF residents between 75 and 84 years of age doubled (IRR = 2·7; 95% CI 1·8-3·9) compared with their community counterparts. The CFR among community-acquired cases was higher in LTCF residents than community residents (21% vs. 11%). Age remained associated with death in our final model. Our study showed that, even controlling for age, LTCF residents have a higher risk of acquiring and dying from iGAS. Whilst existing co-morbidities may explain this, it is reasonable to assume that the institutional setting may facilitate transmission. Therefore, cases in LTCF require prompt investigation together with a better understanding of factors contributing to the acquisition of infection.
Introduction: Collaborative practice agreements have been utilized to expand pharmacist roles and improve patient care outcomes. A need to reduce the time providers spend reviewing oral oncolytic prescriptions for therapy continuation or dose adjustments was identified in the oncology clinics of a community health system. A collaborative practice agreement was created to decrease turnaround time for processing oral oncolytic prescriptions, improve provider satisfaction, and decrease patient prescription costs. Methods: A three-month pilot was initiated to evaluate feasibility and provider satisfaction by comparing two provider groups. An additional three months of data were collected post-collaborative practice agreement implementation to evaluate impact. Primary endpoints included: interventions, turnaround time, and patient cost savings. A survey was conducted to determine provider satisfaction. Results: The mean turnaround time for pharmacist interventions in the pilot group (n ¼ 54) was 7 min, compared to 3311 min in the control group (n ¼ 87), which was statistically significant (p < 0.0001). Two interventions in the pilot group resulted in patient cost savings due to dose rounding by a pharmacist. The mean turnaround time of the postcollaborative practice agreement group (n ¼ 197) was 6 min, which was statistically significant when compared to the control group (p < 0.0001). Conclusion: Turnaround time was significantly shorter for prescriptions in the pilot and post-collaborative practice agreement groups compared to the control group. Provider satisfaction increased as the collaborative practice agreement resulted in less time reviewing oral oncolytic prescriptions. Patient costs were also reduced during the pilot phase due to dose rounding by pharmacists.
In the United Kingdom, pertussis guidance recommends prophylaxis for household contacts within 21 days of case symptom onset if the household includes a vulnerable contact. The aim of our study was to identify characteristics associated with cases reported late for public health action. We reviewed the epidemiology of cases reported in London and South East England for the period 2010 to 2015. We characterised risk factors associated with late reporting of cases and described public health actions taken on timely reported cases. From 2010 to 2015, 9,163 cases of pertussis were reported to health protection teams. Only 11% of cases were reported within 21 days of onset, limiting opportunities for secondary prevention. Timely reporting was associated with younger age groups, pregnancy, being a healthcare worker and being reported by schools or hospital clinicians. Late reporting was associated with older age groups and general practitioner or laboratory reporting. Delays, such as those due to insidious onset and late presentation to healthcare, may be unavoidable; however, delay in reporting once a patient presents can be reduced since cases can be reported before laboratory confirmation. Thus we recommend working with clinicians and laboratories to determine causes and improve early reporting to public health.
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