years, with symptomatic achalasia proven by manometry and radiology were studied. Twelve patients were newly diagnosed as having achalasia and had received no previous treatment while the remaining five had previously undergone pneumatic dilatation of the cardia on one or more occasions but had developed recurrence of dysphagia.All patients were admitted to hospital for their pretreatment assessment and this allowed the diagnosis of achalasia to be confirmed in new patients. After an overnight fast the patients underwent 24 hour oesophageal pH monitoring using a pH sensitive radio telemetric capsule and portable receiving equipment (MR 1000 solid state system, Oxford Medical Systems Ltd).4 The capsule was placed 5 cm above the proximal end of the lower oesophageal sphincter as identified manometrically and tethered using a fine nylon thread taped to the cheek. Signals from the capsule were detected by an aerial belt around the chest connected to a solid state recorder. For the duration of the study patients were encouraged to be fully ambulant in the hospital 883 Smart, Foster, Evans, Slevin, and Atkinson environment and food with a pH value of less than 5 was avoided. At the end of the study the data was played back using a micro processor controlled playback unit linked to a standard digital printer. Data were analysed by calculating the time below pH5 and below pH4 expressing each as a percentage of the total, day and night recording period thus obtaining a percentage acid exposure time (%AET).After a 12 hour fast the patients underwent endoscopy and pneumatic dilatation of the cardia using the Rider-Moeller bag under general anaesthesia.5 The presence of food residue in the oesophagus was noted and a sample collected for measurement of its pH, titratable acidity and organic acid content using gas liquid chromatography.One week after pneumatic dilatation the 24 hour oesophageal pH study was repeated. STATISTICAL ANALYSISThe %AET was calculated for patients before and after pneumatic dilatation. The values were compared between groups of patients using the Mann Whitney U test for non-parametric data. ResultsFor purposes of analysis and comparison the patients were divided into two groups; the nine with oesophageal food residue at endoscopy and the remaining (Fig. 1). Analysis of the oesophageal residue obtained from patients with retained food revealed this to be acidic (median pH 3-8, range 3.5-4.0). The acidity of the residue was found to be largely caused by the lactic acid content which accounted for between 91 and 97% of the total acid.After pneumatic dilatation no food residues remained and acid exposure tended to be greater in patients with than in those without initial food residue but this difference was only significant for nocturnal pH measurement (Fig. 2). Those patients with initial food residue showed a fall in total %AET for both pH values after pneumatic dilatation. These changes were less marked at night than during the day (Fig. 3). In those patients without initial food residue, pneumatic d...

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Background Escherichia coli (E. coli) comprise part of the normal vaginal microflora. Transfer from mother to neonate can occur during delivery resulting, sometimes, in neonatal bacterial disease. Here, we aim to report the first outbreak of CTX-M ESBL-producing E. coli with evidence of mother-to-neonate transmission in an Irish neonatal intensive care unit (NICU) followed by patient-to-patient transmission.MethodsInvestigation including molecular typing was conducted. Infection was defined by clinical and laboratory criteria and requirement for antimicrobial therapy with or without positive blood cultures. Colonisation was determined by isolation without relevant symptoms or indicators of infection.ResultsIndex case was an 8-day-old baby born at 34 weeks gestation who developed ESBL-producing E. coli infections at multiple body sites. Screening confirmed their mother as colonised with ESBL-producing E. coli. Five other neonates, in the NICU simultaneously with the index case, also tested positive. Of these, four were colonised while one neonate developed sepsis, requiring antimicrobial therapy. The second infected neonate’s mother was also colonised by ESBL-producing E. coli. Isolates from all eight positive patients (6 neonates, 2 mothers) were compared using pulsed-field gel electrophoresis (PFGE). Two distinct ESBL-producing strains were implicated, with evidence of transmission between mothers and neonates for both strains. All isolates were confirmed as CTX-M ESBL-producers. There were no deaths associated with the outbreak.ConclusionsResources were directed towards control interventions focused on hand hygiene and antimicrobial stewardship, which ultimately proved successful. Since this incident, all neonates admitted to the NICU have been screened for ESBL-producers and expectant mothers are screened at their first antenatal appointment. To date, there have been no further outbreaks.

BackgroundCarbapenemase-producing Enterobacteriaceae (CPE) can cause healthcare-associated infections with high mortality rates. New Delhi metallo-beta-lactamase-1 (NDM-1) is amongst the most recently discovered carbapenemases. AimTo report the first outbreak of NDM-1 CPE in Ireland, including microbiological and epidemiological characteristics, and assessing the impact of infection prevention and control measures. MethodsRetrospective microbiological and epidemiological review. Cases were defined as patients with a CPE positive culture. Contacts were designated as roommates or ward mates. FindingsThis outbreak involved ten patients, with a median age of 71 years (range 45-90 years), located in three separate but affiliated healthcare facilities. One patient was infected (the index case); the nine others were colonised. Nine NDM-1-producing Klebsiella pneumoniae, a NDM-1-producing Escherichia coli and a K. pneumoniae carbapenemase (KPC)-producing Enterobacter cloacae were detected between week 24 2014 and week 37 2014. Pulsed field gel electrophoresis demonstrated similarity. NDM-1 positive isolates were meropenem resistant with MICs ranging from 12 to 32 µg/ml. All were tigecycline susceptible (MICs ≤1 µg/ml). One isolate was colistin resistant (MIC 4.0 µg/ml; mcr-1 gene not detected). In 2015, four further NDM-1 isolates were detected. Conclusions 3The successful management of this outbreak was achieved via the prompt implementation of enhanced infection prevention and control practices to prevent transmission. These patients did not have a history of travel outside of Ireland, but a number had frequent hospitalisations in Ireland, raising concerns regarding the possibility of increasing but unrecognised prevalence of NDM-1 and potential decline in value of travel history a marker of colonisation risk. KeywordsCarbapenemase-producing Enterobacteriaceae, New Delhi metallo-beta-lactamase-1 (NDM-1), multi-drug resistant organism, outbreak, Ireland. Study definitionsCases were defined as patients with a NDM-1 positive culture from any site during their hospitalisation. Contacts were designated as roommates or ward mates. Microbiological and molecular detection of NDM-1Since 2011, CPE surveillance at UHL had been performed on stool samples or rectal swabs using KPC-producer selective chromogenic agar (CHROMagar™ KPC, Paris, France).MALDI-TOF MS (Bruker Diagnostics) identification was performed on all colonies, as previously described 22 . Antimicrobial susceptibility testing was performed using broth microdilution (ARIS Sensititre ® system-Thermo Fisher Scientific Inc, Masachusettts, USA).Elevated carbapenem minimum inhibitory concentrations (MICs) for meropenem and ertapenem were confirmed by E-test (AB Biodisk, Solna, Sweden) following the European Committee on Antimicrobial Susceptibility Testing (EUCAST) guidelines; ertapenem resistance MIC >1 g/l, meropenem resistance MIC >8 g/l. Isolates with elevated carbapenem MICs were further evaluated using the modified Hodge test (MHT). Commercially available 7 diagnos...