Background UK migrants born in intermediate to high prevalence areas for blood borne viruses (BBV) including hepatitis B, hepatitis C and HIV are at increased risk of these infections. National guidance from Public Health England (PHE) and National Institute for Health and Care Excellence (NICE) recommends primary care test this population to increase diagnoses and treatment. We aimed to investigate primary care professionals’ knowledge of entitlements, and perceptions of barriers, for migrants accessing healthcare, and their policies, and reported practices and influences on provision of BBV testing in migrants. Methods A pre-piloted questionnaire was distributed between October 2017 and January 2018 to primary care professionals attending the Royal College of General Practitioners and Best Practice in Primary Care conferences, via a link in PHE Vaccine Updates and through professional networks. Survey results were analysed to give descriptive statistics, and responses by respondent characteristics: profession, region, practice size, and frequency of seeing migrant patients. Responses were considered on a per question basis with response rates for each question presented with the results. Results Four hundred fourteen questionnaires were returned with responses varying by question, representing an estimated 5.7% of English GP practices overall. Only 14% of respondents’ practices systematically identified migrant patients for testing. Universal opt-out testing was offered to newly registering migrant patients by 18% of respondents for hepatitis B, 17% for hepatitis C and 21% for HIV. Knowledge of healthcare entitlements varied; fewer clinical staff knew that general practice consultations were free to all migrants (76%) than for urgent care (88%). Performance payment structure (76%) had the greatest reported influence on testing, followed by PHE and Clinical Commissioning Group recommendations (73% each). Language and culture were perceived to be the biggest barriers to accessing care. Conclusions BBV testing for migrant patients in primary care is usually ad hoc, which is likely to lead to testing opportunities being missed. Knowledge of migrants’ entitlements to healthcare varies and could affect access to care. Interventions to improve professional awareness and identification of migrant patients requiring BBV testing are needed to reduce the undiagnosed and untreated burden of BBVs in this vulnerable population.
Objectives: Detection of rarer carbapenemases is challenging, as it requires molecular assays with comprehensive coverage or the use of phenotypic methods for the detection of carbapenemase activity. We describe a new class A carbapenemase, FRI-2, in an Enterobacter cloacae complex isolate following implementation of an inhouse multiplex PCR for the detection of 'rare' class A carbapenemases.Methods: MICs were determined by agar dilution. A carbapenem-resistant E. cloacae complex isolate was tested by PCR for the class A carbapenemases bla KPC , bla FRI , bla IMI , bla GES and bla SME . Carbapenemase activity was assessed using Carba NP and the carbapenem inactivation method. Whole genome and plasmid analyses of the clinical isolate and the FRI-2 transformant were performed by WGS, respectively. Typing was carried out by PFGE.Results: The E. cloacae complex isolate showed resistance to imipenem (MIC " 16 mg/L), meropenem (MIC " 8 mg/L) and ertapenem (MIC " 8 mg/L), but remained susceptible to piperacillin/tazobactam (MIC " 8 mg/L). Carbapenemase activity was confirmed in the isolate by both phenotypic methods. A bla FRI-1-like gene was detected by PCR and analysis of WGS data of the clinical isolate identified an ORF of 885 bp , which showed 97% nucleotide identity with bla FRI-1 and was named bla FRI-2 . WGS of the transformant indicated bla FRI-2 was located on a 108 kb IncF/IncR plasmid. The FRI-2-positive E. cloacae complex isolate belonged to a novel ST (ST829). Conclusions:The possible circulation of rarer carbapenemases in clinical settings highlights the role of phenotypic tests to detect carbapenemase activity when molecular assays are negative for the 'big 5' carbapenemase families. IntroductionIn Enterobacteriaceae, carbapenem resistance mediated by carbapenemases is mostly attributed to the interspecies dissemination of KPC, OXA-48-like, NDM, VIM and IMP alleles. Although the dispersion of the 'big 5' carbapenemases has been reported worldwide, some carbapenemases, such as bla SME or bla SPM , are still species-or, largely, country-specific. 1,2 Class A carbapenemases other than KPC include the closely related NMC-A and IMI, SME, GES, BIC-1, SFC-1 and BKC-1. 3 The detection of these carbapenemases poses a problem in terms of infection prevention and control as most commercial and in-house molecular assays have limited coverage and focus on the detection of the 'big 5' families. Moreover, due to the rarity of these other carbapenemases and their potential susceptibility to cephalosporins, phenotypic tests could be misinterpreted as falsepositives if further extended molecular characterization is not undertaken. 4 Dortet et al. 5 recently identified a novel class A carbapenemase, FRI-1, in an isolate of Enterobacter cloacae in a patient in France. FRI-1 shares 53% and 42% identity with SFC-1 and BKC-1, respectively, and is related to a subgroup including SME-1, IMI-1 and NMC-A, with identity ranging from 54% to 56%.PHE's Antimicrobial Resistance and Healthcare Associated Infections (AMRHAI) Reference U...
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