The occurrence of Francisella tularensis outside of endemic areas, such as North America and Eurasia, has been enigmatic. We report the metagenomic discovery and isolation of F. tularensis ssp. holarctica biovar japonica from diseased ringtail possums in Sydney, Australia. This finding confirms the presence of F. tularensis in the Southern Hemisphere.

We report a case of ulceroglandular tularemia that developed in a woman after she was bitten by a ringtail possum (Pseudocheirus peregrinus) in a forest in Tasmania, Australia. Francisella tularensis subspecies holarctica was identified. This case indicates the emergence of F. tularensis type B in the Southern Hemisphere.

CRP levels are higher after open surgery compared with laparoscopic surgery, both with and without AL. AL generates a significant detectable increase in CRP within 2-4 days after surgery.

IntroductionIncreasing pressure and limitations on the NHS necessitate simple and effective ways for maintaining standards of patient care. This quality improvement project aims to design and implement user-friendly and clear ward round stickers as an adjunct to surgical ward rounds to evidence standardised care.Project design and strategyBaseline performance was measured against the recommended standards by the Royal College of Physicians, General Medical Council and a study performed at the Imperial College London. A total of 16 items were studied. All members of staff in surgery department were informed that an audit on ward round entries would be implemented but exact dates and times were not revealed. In the first cycle, ward round sticker was implemented and results collected across three random days for use and non-use of sticker. Feedback was collected through the use of questionnaires. In the second cycle, the ward round sticker was redesigned based on feedback and results collected for use and non-use of sticker.ResultsBaseline performance noted in 109 ward round entries showed that checking of drug chart, intravenous fluid chart, analgesia, antiemetic, enoxaparin, thromboembolic deterrents ranged from 0% to 6%. With the introduction of ward round stickers in both cycles, there was noticeable improvement from baseline in all items; in ward round entries where stickers were not used, performance was similar to baseline.ConclusionThis quality improvement project showed that the use of stickers as an adjunct to surgical ward round is a simple and effective way of evidencing good practice against recommended standards. Constant efforts need to be made to promote compliance and sustainability. Commitment from all levels of staff are paramount in ensuring standardised patient care without overlooking basic aspects.

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dInfant botulism is a potentially life-threatening paralytic disease that can be associated with prolonged morbidity if not rapidly diagnosed and treated. Four infants were diagnosed and treated for infant botulism in NSW, Australia, between May 2011 and August 2013. Despite the temporal relationship between the cases, there was no close geographical clustering or other epidemiological links. Clostridium botulinum isolates, three of which produced botulism neurotoxin serotype A (BoNT/A) and one BoNT serotype B (BoNT/B), were characterized using whole-genome sequencing (WGS). In silico multilocus sequence typing (MLST) found that two of the BoNT/A-producing isolates shared an identical novel sequence type, ST84. The other two isolates were single-locus variants of this sequence type (ST85 and ST86). All BoNT/A-producing isolates contained the same chromosomally integrated BoNT/A2 neurotoxin gene cluster. The BoNT/B-producing isolate carried a single plasmid-borne bont/B gene cluster, encoding BoNT subtype B6. Single nucleotide polymorphism (SNP)-based typing results corresponded well with MLST; however, the extra resolution provided by the whole-genome SNP comparisons showed that the isolates differed from each other by >3,500 SNPs. WGS analyses indicated that the four infant botulism cases were caused by genomically distinct strains of C. botulinum that were unlikely to have originated from a common environmental source. The isolates did, however, cluster together, compared with international isolates, suggesting that C. botulinum from environmental reservoirs throughout NSW have descended from a common ancestor. Analyses showed that the high resolution of WGS provided important phylogenetic information that would not be captured by standard seven-loci MLST. Genomic epidemiology has provided novel insights into the genetic characteristics and phylogenetic diversity of botulinum neurotoxin (BoNT)-producing Clostridium species (1-8).BoNT subtypes are responsible for causing the serious paralytic disease botulism and their potent neuroparalytic activities make them one of the top (tier 1) agents considered to pose a significant threat to public health if used for bioterrorism (Electronic Code of Federal Regulations-Title 42: Part 73; http://www.ecfr.gov/cgi -bin/retrieveECFR?rϭPART&nϭ42y1.0.1.6.61) (9, 10). The same properties also make them powerful tools for both medical therapeutic and cosmetic applications (11).Botulism is a very rare disease in Australia (National Notifiable Diseases Surveillance System [NNDSS]; http://www9.health.gov .au/cda/source/cda-index.cfm), with only 20 cases reported since 1991. However, a global survey found that Australia had one of the highest numbers of notified cases of infant botulism in the world (12, 13). Infant botulism results from the ingestion of Clostridium botulinum spores which germinate and temporarily colonize the infant's colon, followed by growth of vegetative cells that produce . This form of the disease only occurs in infants, generally under 1 year old, as they h...

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Coxiella burnetii is the causative bacterium of Q fever, a vaccine-preventable infection. C. burnetii is an unusual cause of culture-negative endocarditis. Here, we present a case of Q fever native valve endocarditis that developed in a young man despite prior vaccination. Definitive diagnosis was difficult and required C. burnetii-specific PCR testing. Case reportA 29-year-old Australian man was admitted in April 2012 for elective aortic and mitral valve replacement for progressive severe aortic and mitral regurgitation with mild aortic root dilatation from Marfan's syndrome. His past medical history included a meticillin-susceptible Staphylococcus aureus-colonized chronic left leg ulcer requiring oral flucloxacillin 500 mg four-times daily, chronic fatigue syndrome and recent partial dental clearance. He denied intravenous drug use. He lived in a country town where he worked as a house painter.A St Jude mitral and aortic valve replacement was performed with preservation of the aortic root. An intraoperative diagnosis of native valve infective endocarditis was suspected due to the appearance of concurrent healed aortic and mitral valve vegetations. Interestingly, his preoperative transoesophageal echocardiogram was normal.Post-operatively, further history of occupational and environmental exposures relevant to endocarditis was obtained. Cat scratches, farm animal exposure, ingestion of unpasteurized milk and abattoir work raised the possibility of Bartonella spp., Brucella spp. and Coxiella burnetii (Q fever) as infectious aetiologies. Twelve years earlier (late March 2000), he commenced work at a local abattoir. At commencement of employment, he underwent a medical review and was screened for Q fever on 28 March 2000: baseline serology was negative (immunofluorescence phase II antibody ,10, complement fixation test against phase II antigen ,2.5), and a skin test using 0.5 ml purified killed suspension of C. burnetii was also negative. Documentation illustrates that he was subsequently vaccinated 7 days later with Q-Vax (CSL Biotherapies Q fever vaccine 0.5 ml containing 25 mg purified killed suspension of C. burnetii). He worked at the abattoir for 8 months. Approximately 9 months later, he reported to his local medical officer with unexplained loss of weight (30 kg) and fatigue. In the intervening years prior to cardiac surgery, he also reported intermittent drenching night sweats; however, C. burnetii serology was not performed nor did he receive any antibiotic treatment other than flucloxacillin for his leg ulcer.Physical examination was remarkable for marfanoid features and chronic venous insufficiency of his left leg without active infection. An orthopantomogram excluded an odontogenic source of infection. Blood cultures performed intraand post-operatively revealed Staphylococcus hominis in 1 of 12 bottles; this was judged to represent contamination, and other culture bottles remained negative with extended incubation to 21 days. There were polymorphonuclear leukocytes on aortic and mitral valve tissue, b...