Blood culture is the cornerstone of an established aetiological diagnosis of septicaemia. The automated blood culture systems used for this purpose have changed little in the last decade, and the clinical value of results depends on a variety of factors, including pre-and post-analytical variables. Growing scepticism over the value of blood culture results and pressure for the introduction of molecular detection systems have prompted a critical path analysis of pre-, peri-and post-analytical stages in the generation of positive blood culture results. The impact of a positive blood culture was studied in a teaching hospital for 12 months before and 12 months after the introduction of a microbiologist's blood culture round. Active culture reporting via a blood culture ward round was supported by a personal data assistant database of contemporaneous laboratory and clinical data. Hospital occupancy and death register records were subsequently obtained through the State Government data linkage project. There was no evidence that faster laboratory generation of positive blood culture results, faster reporting of results or direct clinical interaction with the patient's primary medical team reduced the risk of death in hospital. However, there was a threefold increase in the rate of death in hospital following a 1 day delay in collection of blood cultures after hospital admission (P50.0010). The overall duration of hospital stay for patients with a positive blood culture fell by 2.5 days compared with the previous 12 month period (P50.0003). The interval between the initial positive culture result and patient discharge fell by 2 days (P50.0010). This difference was attributed to shorter overall admissions and shorter intervals between positive cultures containing Gram-positive cocci and subsequent patient discharge (P50.0018). An increased mortality rate from community-acquired bacteraemic infections was associated with delayed culture collection, but not with a prolonged laboratory processing interval. Thus, the speed of conventional blood culture analysis and the form of clinical reporting have little direct effect on the clinical outcome of bacteraemia, but may contribute to a reduction in the length of hospital admission. Introduction of molecular identification tests, such as multiplex PCR methods, at the Gram-stain stage of blood culture is unlikely to affect the rate of death in hospital, but may reduce the length of hospital admission.
f Peritoneal dialysis is the renal replacement modality used by ϳ20% of patients with end-stage kidney disease (S. McDonald, P. Clayton, and K. Hurst, p. 6.2-6.27, in ANZDATA 2012 Annual Report, 35th ed., 2012). A major complication of peritoneal dialysis is the development of peritonitis. We describe a case of Humicola sp. causing peritoneal dialysis (PD)-associated peritonitis, successfully treated with a prolonged course of antifungal therapy. CASE REPORTA 41-year-old female with end-stage renal failure secondary to systemic lupus erythematosus on peritoneal dialysis (PD) presented to the emergency department with generalized abdominal pain and cloudy PD bags. White cell count (WCC) in the peritoneal fluid was 1,080 ϫ 10 6 /liter, and empirical treatment was commenced with intraperitoneal (IP) vancomycin and gentamicin, as per current protocols. As she was clinically stable, she was discharged home. Three days later, she presented again with increasing abdominal pain and PD bags that remained cloudy. Cultures from her original samples remained negative, and oral ciprofloxacin was commenced. Due to increasing abdominal symptoms, she agreed to inpatient care and was transferred to our hospital. On examination, when she arrived there was generalized abdominal tenderness on deep palpation, and minimal bowel sounds were audible. The PD catheter exit site was clean with no signs of erythema. The patient was afebrile (37°C) and hemodynamically stable. Blood tests showed a hemoglobin (Hb) of 99 g/dl, WCC of 7.0 ϫ 10 9 /liter, platelet count of 135 ϫ 10 9 /liter, and a C-reactive protein (CRP) level of 160 mg/liter.In addition to lupus nephritis, her medical history included avascular necrosis secondary to steroids requiring bilateral hip replacements, a nontraumatic left below-knee amputation, a right ankle arthrodesis, and hypertension. Her regular medications were calcitriol, darbepoetin, and gabapentin. Of note, she reported that she had been snorkeling and scuba diving in the ocean 3 to 4 weeks prior to this presentation.On the third day after her admission, due to persisting abdominal pain and cloudy dialysate, the PD catheter was removed and hemodialysis was commenced using an existing left arteriovenous (AV) fistula. Over the next 6 days, repeated imaging showed increasing ascites and peritoneal enhancement consistent with ongoing peritonitis. No discrete abscesses or collections were visualized, and standard bacteriology cultures of PD fluid remained negative. Transthoracic and transesophageal echocardiograms did not show infective endocarditis. As she remained febrile and unwell, with nonresolving intra-abdominal collections, a further laparotomy was performed. Visual inspection of the peritoneum revealed multiple white patches with cloudy ascitic fluid, and a fluid WCC was 50 ϫ 10 6 /liter. Further samples for culture were taken, and a washout was performed. Empirical antimicrobial therapy with intravenous (i.v.) piperacillin-tazobactam and amphotericin B was commenced. Seventeen days later, due to ongoing ...
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