Mr R Chapman
One of the most far reaching of the Government’s NHS reform and modernisation policies is the creation of Primary Care Groups and Trusts with the responsibility and accountability for both the commissioning of Secondary Care services and the provision of Primary Care and Community Services. This session will look at the impact of Primary Care Groups during their first 18 months of existence and the more radical changes expected as Primary Care Trusts commence the provision of services currently
provided by Community and Hospital Trusts.
Clinical Benchmarking
Mr K Barr , Preston
There is an increasing belief that there is urgent need for detailed comparative performance analysis within the public sector. Benchmarking is a recognised management tool, which involves processes to identify superior performance, and enables organisations from all business sectors to answer three fundamental questions:
How does our performance compare with similar organisations?
The White papers on the future of the NHS published in 1997 and 1998 emphasised the Government’s commitment to benchmarking as a management technique to allow comparison of key indicators of performance between NHS bodies. However, the success of benchmarking is limited by the extent to which inputs, processes, outputs and qualities can be quantified.
For a benchmarking exercise to be worthwhile the methodology needs to lead to valid, comparable and relevant data and the application of the data must be in a defined and specific context.
In the case of pathology services there are a number of factors that must be present to make benchmarking successful:
1. The co-operation and active involvement of departments from a significant sample size.
There is an acceptance that the CBC/Keele University benchmarking scheme has been very successful in the NHS over several years based on a bottom up approach of refining the counting nomenclature and the data collected for comparison based on the active feedback of the participants of the scheme and the expert panels drawn from a wide range of professions and backgrounds.
My presentation will outline some of the key do’s and don’ts associated with benchmarking and show some of the useful outputs that can lead to improved laboratory performance in the hands of laboratory managers committed to top quality services, effectively and efficiently provided delivering excellent value for the investment of considerable public money.
Clinical Governance
Dr. T.A. Gray, Sheffield.
Clinical governance is an evolving concept developed by the Government to describe the adaptation of the principles of corporate governance to clinical activity and clinical staff involved. The Scope includes the optimisation of clinical care, quality management, monitoring arrangements and continuing staff development.
The basis of the optimisation of patient care is the growing evidence base of clinical practice and the standardisation of operational procedures which will be strengthened by the establishment of NICE. In the field of cancer care, the standardisation started some years ago in the Calman-Hine report, and this is in the process of being extended to other fields of clinical activity in the National Service Frameworks. In pathology, of course, External Quality Assessment and accreditation procedures have become the accepted norm but these are still in their infancy in other areas of medicine.
The Government has placed great emphasis on the monitoring of clinical activity, audit and risk management to try and avoid untoward incidents which have dented the trust that the general public place in the NHS. Further, direct lines of accountability for quality management have to be established in each clinical area right up to the Chief Executive, who is now statutorily responsible for quality.
All this places a greater burden on staff but the intention is that they are to be supported through professional self-regulation and personal Continuing Professional Development. This talk will briefly review these changes and try to assess the impact on pathology and the staff involved.
Quantal Microbiology
Dr E Bridson, Camberley
Practical microbiology has been, from its beginnings in the late 1800s, the study of mass populations of micro-organisms. Whilst single cells can be observed by microscopy and individual cell components have been identified, even approximately quantified, few biologists care to struggle with the individual cell. More commonly, armed with the understanding that in single cell cultivation each propagated microbial cell is identical, analysts work with 105 – 108 cells per ml. The analytical conclusions reached are accepted to be probability estimates of identical cell populations. In view of the stormy history of the development of prokaryotes it is unlikely, however, that the cells are identical and small differences between them could distinguish surviving cells in various adverse conditions.
The prokaryotes are the oldest form of life on earth (ca. 3.5 x 109 years) and have successfully modified the earths atmosphere so that higher forms of life were able to develop about 500 million years ago. Their survival through the initial very harsh planetary conditions was possible because of their short generation time and significant differences in the abilities of individual cells to adapt to constant change. In the relative calm of the Phanerozoic eon (570 million years ago to the present date) it is possible that more stable selective adaption of micro-organisms to particular eco-niches developed, thus forming reproducible groups that we call tribes, families, genera and species. The outstanding ability of micro-organisms to adapt to change, however, has been lost.
Quantal microbiology is concerned with individual micro-organisms and this presentation draws an analogy between Classical physics v. quantum mechanics with classical microbiology v. quantal microbiology.
The Rise and Rise of Dengue Fever
Dr J R Stephenson, London
Following the ecologic disruption both during and after the Second World War there was a rapid increase in the activity of the mosquito vectors for dengue virus. Both epidemic transmission and hyperendemicity developed rapidly in many S.E. Asia cities. The first epidemic of haemorrhagic form of dengue fever (DHF) occurred in Manila in 1953 and by 1970 DHF had spread throughout the S.E. Asian region. Epidemics had returned to the Americas by 1980 and by 1997 dengue virus and its mosquito vector had a global distribution in the tropical regions of the world, including the southern states of the USA. Thus a third of the world’s population is at risk from this disease and 100 million cases are reported every year. Several hundred thousand of these cases result in DHF, which is the leading cause of hospitalisation and death among children in S.E. Asia.
A further complication to understanding the pathogenesis of this disease and to its control, is the possible role of antibody dependent enhancement of infection (ADE). There is now a considerable body of evidence to show that ADE can occur in vitro and several observations to suggest that it has a role in dengue pathogenesis in vivo. ADE is thought to occur through low levels of pre-existing non-neutralising, but cross-reactive, IgG antibodies to the major virion envelope protein. These antibodies can bind to Fc-receptor bearing cells and the antibody-Fc receptor complex can act as a surrogate receptor for the virus. As the antibody is incapable of neutralising the virus it can enter the cell, replicate and kill it. Fc receptor-bearing cells are frequently important components of the body’s immune defences and therefore their deaths in large numbers could serious impair the immune response and result in severe or fatal disease.
Dengue virus and its mosquito vector have been particularly difficult to control and there are no licensed drugs or vaccines available, despite hundreds of millions of dollars of research funding over several decades. Factors responsible for the continuation of this major threat to world health will be discussed, along with novel strategies for vaccine development.
Toxoplasmosis
Dr R Holliman, London
Clinical illness associated with congenital and post-natal, acute toxoplasma infection is well described. The clinical sequelae of chronic toxoplasmosis are, however, uncertain.
In animal studies, chronic toxoplasma infection has been shown to be associated with altered behaviour including, increased movement in mice and diminished fear of novel scent, sound or sight in rats. In both species this altered behaviour may lead to an increased propensity to feline predation, thus completing the life cycle of the parasite. It is proposed that neurotropic cysts of Toxoplasma gondii exert an effect on animal behaviour, either directly or via the excretion of metabolic products.
In humans, one study demonstrated a significant association between long standing toxoplasma infection and meningioma, but not glioma. Personality testing of University staff and students found an association in men with long standing infection and less desirable behavioural patterns such as expediency, rule breaking, suspicious nature, jealousy, being dogmatic and suffering from feelings of guilt. Conversely, infected females were more likely to be self-sufficient and to feel adequate than their non-infected colleagues. In both sexes, the degree of personality shift increased with the duration of toxoplasma infection suggesting infection gave rise to personality change and not vice-versa.
Given that one third to one half of the entire population of the world have long standing toxoplasma infection this potential for adverse sequelae deserves further study.
New Technologies for the Diagnosis of
Genital Chlamydia infections
Dr G.L.Ridgway , London
Chlamydia trachomatis is an obligate intracellular bacterium. In consequence, it cannot be cultured on or in artificial media. Cell culture methods although highly specific, are technically demanding and not as sensitive as originally suggested. Increasing demand for a diagnostic service has increased pressure to develop alternative means of laboratory diagnosis, and as new techniques became available so their application to chlamydial diagnosis became one of the first uses, with variable success.
Attempts to use fluorescent antibodies were disappointing until the advent of monoclonal antibodies. Direct immunofluorescence (IF) remains a useful technique, but also suffers from being technically demanding. Enzyme immunoassay (EIA) technology appeared to be the answer. Large numbers of specimens could be processed using semi-automation, and maintenance of quality was relatively straightforward. In general, EIA results compared well with cell culture, although sensitivity was always less. Specificity presented problems and a blocking assay or immunofluorescence should always confirm EIA positive results. DNA hybridisation methods have similar sensitivity to EIA.
Then came the diagnostic revolution of amplified molecular technology. It was soon apparent that EIA, and cell culture considerably underestimated the prevalence of chlamydial genital infection. Polymerase chain reaction (PCR) was the first test to become commercially available, and specificity compared with cell culture caused early concern. Comparison with IF or the use of alternate PCR primers confirmed that it was cell culture that was insensitive, and not a lack of PCR specificity. Similar problems were noted with ligase chain reaction (LCR), a technique which should have increased specificity compared with PCR because of the use of probes instead of primers. The increased sensitivity of the technologies had to be countered by an upgrading of discipline in the routine laboratory to avoid contamination with nucleic acids, and the commercial systems have been designed with this problem in mind.
Amplified molecular techniques are suitable for use on non-invasive samples such as urine specimens from men and women. The ability to test urines from women is important, because other techniques (e.g. EIA) are not sensitive enough for this purpose, and should not be used. However, there is no doubt that test inhibitors in some urines are particularly a problem with PCR, and to a lesser extent with LCR. Identified inhibitors include beta-HCG and crystals for PCR and nitrites for LCR. Most inhibitors can be removed by overnight storage at 40C or freezing at-700C. Recent studies have suggested that vulval swabs are an even more convenient sample for chlamydial PCR or LCR, with a sensitivity similar to cervical sampling.
New technologies continue to be developed. Transcription Mediated Amplification (TMA) and Strand Displacement Assay (SDA) are commercially available. The major drawback to amplified molecular technology is cost. These tests are 2 - 3 times more expensive than the more widely available EIA. But since the latter are only detecting some 50 - 60% of all infections, their continued use in the face of more sensitive and specific technologies must be seriously questioned. Chlamydial genital infection in women continues to be the major cause of involuntary infertility. Screening programmes with sub-optimal tests are clearly an inappropriate use of valuable resources.
Mycobacterial Infections: A Critical Assessment of their
Laboratory Diagnosis
Dr J Magee, Newcastle
A world-wide resurgence of tuberculosis and the appearance of multi-drug resistant tuberculosis (MDR-TB) have emphasised the vital role of the laboratory in the diagnosis of this disease. Additionally, the impact of non-tuberculosis mycobacteria in vulnerable groups has highlighted difficulties in the detection and isolation of these increasingly important species. In facing these challenges, laboratories must adopt procedures which allow rapid, and effective detection of mycobacteria. However, they must also accept the limitations of new approaches and the economic constraints imposed by their adoption.
Amplified and non-amplified molecular procedures can aid in the detection and characterisation of some mycobacterial species and assays for the detection of resistance genes are becoming available. However, each of these techniques implies an increase in cost of both a financial and organisational nature and they should be thoughtfully applied. In contrast, conventional techniques for the diagnosis of mycobacterial infections are capable of dramatic improvement. Pre-digestion of samples combined with fluorescence staining has enhanced the sensitivity of microscopy. Similarly, Continuous Automated Liquid Culture methods have once again established culture as the gold standard for mycobacterial investigations and offer the possibility of a rapid flexible approach to susceptibility testing. The conventional and molecular laboratory approaches to the diagnosis of mycobacterial infections can however be integrated to provide an optimum diagnostic service.
They need to make effective use of available resources and to achieve an efficient and rapid service can lead to implications for the organisation of mycobacterial laboratory work. It may be that the nettle of regionalisation will have to be grasped. Without a bold approach to the laboratory diagnosis of mycobacterial infections, a two-speed laboratory network may develop to the detriment of both laboratory services and the clinicians and patients we attempt to serve.
New Technology: Diagnosis and Epidemiology
Prof. S P Borriello, London
A revolution is occurring in nucleic acid analysis, bioinformatics, data storage and retrieval, nanotechnology, physics, micro-electronics, and chemistry (polymer, solid state and combinatorial). These seemingly disparate fields are being combined and applied to the detection, identification, and characterisation of pathogens. The once science fiction scenario of taking a drop of blood, urine or saliva and within an hour knowing whether or not a pathogen is present and its antimicrobial resistance potential will soon be a reality. In the medium term future, concurrent information on the patients’ susceptibility to the pathogen and choice of treatment to minimise unwanted side effects will also be available. These developments, particularly with regard to near patient testing, have important implications for the delivery of health care. They will have an impact on primary care, prescribing practice, organisation of pathology laboratories, counselling services, surveillance and epidemiology, and for medico-legal practice. See Borriello S P (1999) BMJ 319:298-301
“Collaborative working between two laboratories
in North Nottinghamshire”
Mr A Pease*, Sutton in Ashfield and Mr A Cross,Worksop
Since 1996, the two microbiology departments in NHS Trusts at Sutton-in-Ashfield and Worksop, Nottinghamshire have operated a collaborative working arrangement. This agreement was established without pressure from the management at either Trust, and was negotiated between staff in both laboratories.
The key aims of the project were to maintain, or improve overall quality and to support the cost effectiveness of both laboratories. These aims have been significantly realised by centralising specific laboratory activities at one of the two centres. For example, culture media is prepared and quality checked on one site only, whilst as a reciprocal measure, non-urgent batch serology is only performed at the other laboratory. It was initially envisaged that the exchange should be ‘equal’ in terms of costs and labour, and although the latter appears to have been achieved, there has been a need for a small financial adjustment at the end of each year.
There is on-going review of those low volume tests referred to other centres, to assess whether they can be performed economically with an acceptable turnaround time for results. Most recently, the serological testing for Hepatitis C antibody has been instituted at one of the laboratories.
Overall quality has been improved by the implementation of a specimen recycling scheme between the two laboratories. Unlike other external schemes this is not performed as a competitive, scored system, but there is a periodic review of results to indicate the reasons for difference in trend and interpretation.
The benefits of the collaboration are proven. There has undoubtedly been a cost saving for both laboratories, and although difficult to quantify, the staff are more productive. There has been a rationalisation of equipment needs, and participation in external quality assurance schemes. Additionally there is now a robust transport system between the laboratories, and this helps to support the proposed contingency plans for the maintenance of service in the event of a major failure in either of the laboratories. Problems have been limited by regular communication and feedback, and the initial concerns regarding ‘loss’ of posts and reduced repertoire of testing have proven to be unfounded.
For the future, both Trusts are in merger discussions with different third party Trusts. When these expected mergers occur, then this could mean the end of the amicable, successful collaboration.
* Presenter
The Path Links Project
Dr P Cowling , Scunthorpe
Path Links is an organisation, which from October 2000, will provide a single-managed Pathology service across the country of Lincolnshire involving the Acute hospitals of Grimsby, Scunthorpe, Lincoln, Boston and Grantham. The whole service will be underpinned by a single IT system and each Pathology discipline will for a directorate accountable to a Management Board of Pathology professionals.
The speaker will explain the structure of Path Links and its evolution from “twinkle in the eye” to reality.
Integration of Laboratory Services
Mr C Wynne, London
The talk will review the arrangements that were in place to provide a Microbiology Service for the then Health Authorities, in the 1970s, and the University links. The reasons for the amalgamation undertaken will be explained and the size and scope of the laboratories described. Problems encountered will be considered with at least partial solutions and a critical review of the success of the merger undertaken.
After a brief description of the present situation there will be an overview of the plans for the West London Pathology provider service.
Drug development - would you gamble your $400 million?
Mr G.S. Tillotson, USA
The development of new pharmaceutical compounds is a process, which has been refined, streamlined, reviewed, and still problems occasionally occur. As international and national regulatory authorities evolve new criteria for the approval of safe and efficacious compounds, pharmaceutical companies have ever more stringent hurdles to jump. According to the OTA (USA) it costs around $400 million spent over a period of 6-8 years to bring a new drug to the market. These costs may escalate depending on the type of agent being developed.
Anti-infective compound introductions have had something of a recent checkered history, particularly the quinolones. Over the last 30 years only one truly new class of antibacterial has been approved, oxazolidenones. All other antibacterials have been modifications of pre-existing core molecules.
There are three pre-approval phases of drug development, during each phase. Critical decisions are made as to whether to move into the next stage. Yet despite the thoroughness of these continuous evaluations there have been three major antibacterial withdrawals for unexpected adverse events. These events were only observed when a significantly larger drug exposure had occurred e.g. 2.5 million patients and trovafloxacin. Hence rigorous post-marketing surveillance is now demanded and further adds to the costs of development of a new agent.
As pharmaceutical companies search for the 'Holy Grail' they will continue to evaluate the risks and potential benefits of all new compounds, but sometimes a 'bum deal' can ruin everyone's plans and hopes.
Resurgence of gonorrhoea in the UK
Dr C A Ison, London
Gonorrhoea is considered to be unequivocally a sexually transmitted infection and as such has been chosen as a marker of unprotected sex. The causative agent is Neisseria gonorrhoeae, an obligate human pathogen that primarily colonises the mucosal surfaces of the anogenital tract. The number of cases of gonorrhoea in England and Wales declined rapidly after the advent of AIDS in the 1980s, probably as a result of safe sex practices and fear of a fatal sexually transmitted disease. However there has been a sustained increase in gonorrhoea since 1995, with approximately half of all cases being seen in London.
There are 32 genitourinary medicine (GU) clinics in the Thames region and they serve a diverse population, some clinics treat predominantly a local population and others attracting patients of a particular sexual orientation from a larger geographical area. London, being a large cosmopolitan city, is also likely to see more imported infection and hence more antibiotic resistance. It is obviously important to monitor gonococcal resistance to antibiotics to instruct clinical practice but this needs to be conducted on a representative sample.
In 1997 the London Gonococcal Working Group was formed and initiated a surveillance programme to monitor changes in susceptibility of gonococci to antimicrobial agents. Gonococcal isolates and limited demographic data are collected over a three month period, June-August, from consecutive patients attending 13 GU clinics. In total these clinics diagnose approx. 85% of all gonorrhoea in London, giving a representative sample. This is the first surveillance programme for gonorrhoea to be established in England and Wales.
An increase was detected in the number of isolates collected at the 10 GU clinics, for which three years of data is available, 12.1% between 1997 and 1998 and 20.4% between 1998 and 19991. A similar increase has been reported nationally between 1998 and 19992. The number of cases was greatest in women between 16-19 years of age and men between 25-34 years but the increase occurred in men and women, irrespective of age or of sexual preference. We have also shown that levels of plasmid-mediated resistance to penicillin and tetracycline are low but that the prevalence of tetracycline-resistance is rising. In contrast chromosomal resistance to penicillin has fallen from 7.6% in 1997 to 1.5% in 1999. High level resistance to ciprofloxacin has also been low and largely imported but has increased in 1999.
N. gonorrhoeae is the second most common sexually transmitted bacterial infection in England and Wales and hence any increase is of concern. Intervention with effective antimicrobial therapy is essential and hence continued surveillance is necessary to monitor trends in resistance.
1. Martin IMC, Ison CA, London Gonococcal Working Group. Rise in gonorrhoea in
London, UK. Lancet 2000; 355:623.
Genital Warts
Dr J Dhar, Derby
Warts are benign skin tumours. Infection of the genital area with warts is usually multifocal and can involve the anogenital skin. It is the most common sexually acquired viral infection in the western world. The aetiological agent is the Human Papilloma Virus (HPV); which infects the epithelial cells. To date more than 70 HPV types have been described, each type showing a particular trophism to specific anatomic sites (Types 11 and 14 have been identified for the condyloma acuminata).
Genital HPV can be classified into low risk and high risk variants. The low risk types 6,11 are commonly associated with external genital warts and are two fold commoner than other types, a common presentation in GU clinics. High risk types 16,18 are associated with carcinogenesis and cervical cancer which is the commonest cause of cancer related deaths in females under 50 years of age (approx. 300,000 deaths annually) world-wide. Though only 1% are estimated to have visible genital warts at any one time a high percentage of the population is infected with one or more HPV types. Estimates vary from 1.5 - 3% in males and females aged 20 – 24 years. Most people do not exhibit overt signs as the body’s defence mechanisms are able to control the infection. Cell mediated immunity plays an important role in wart regression as well as protection against HPV infection.
The goal of treatment is the removal of exophytic warts with amelioration of signs and symptoms which aside from their cosmetic appearance are minor. All available therapies to date, cyto destructive, surgical, immunomodulatory are sub-optimal as HPV is not eradicated by treatment. Recurrence is a problem and treatment response is poor and variable. The persistence of the virus after treatment probably explains the high recurrence rate of clinically apparent disease. The frequent and time consuming nature the treatment, treatment failures, frequent relapses lead to a high burden of morbidity including sexual dysfunction in some groups.
The NHS cervical screening programme does not recommend any change to cervical screening intervals in females with genital warts. Careful follow up with cytology however is recommended in patients with impaired cell immunity i.e. women infected with HIV, renal transplant patients etc, these patients are more likely to have a poor response to treatment, increased relapses and dysplasia.
“Are Sex, Love, Passion and Desire Compatible
with an MLSO marriage?
Dr C O’Mahony, Chester
It is true, “Men are from Mars and Women are from Venus”. How they managed to get on together in a relationship is a source of constant amazement. The though processes are just so different that hurt and misunderstanding are an inevitable feature.
People working within the health care specialities, i.e doctors, nurses, PHLS staff, etc., do work extremely hard and in a conscientious fashion, and often do allow their work to interfere with family life.
Most relationships start off with love and hope, but the realities of jobs, mortgage, children and family life gradually erode into the time available for each other.
Relationship and sex issues will be discussed in a humorous fashion, but there is a message to be taken away at the same time. Much of the talk is based on past experience over many years working in sexual health, and a useful book list is attached, which can help people examine their own lives and get their act together. It’s never to late!
Book List
Men are from Mars, Women are from Venus
Mars and Venus in the Bedroom
Families and How to Survive them
The Road Less Travelled
To Good to Leave, Too Bad to Stay
Becoming Orgasmic
Self Esteem
Feel the Fear, and do it Anyway
FPA Books & Training
Superoxides
Dr G Lindsay,Glasgow
“Superoxidised Water” is produced from the electrochemical activation of a salt solution. Two separate solutions are produced. One of these, the Catolyte, has no sterilising properties but is capable of precipitating metal ions out of solution and has detergent activity; the Anolyte solution contains a complex mixture of reactive ions and free radicals which have broad spectrum antimicrobial properties.
The method of generating these solutions will be described. Results of a program to establish the value of these agents in the disinfection of fibre endoscopes will be presented. This will include both antimicrobial effectiveness and potential adverse effects on equipment and the environment.
Finally the potential application of these solutions in a wide variety of situations will be discussed.
Melioidosis
Dr D Dance,Plymouth
Melioidosis, or infection caused by Burkholderia (formerly Pseudomonas) pseudomallei, is endemic in south east Asia and northern Australia The organism is closely related to B. mallei (the cause of glanders) and B. cepacia. It has a wide host range including mammals (especially sheep, goats and pigs), birds and occasionally reptiles. B. pseudomallei is an environmental saprophyte found in mud and water. The disease occurs mainly during the rainy season amongst people in contact with soil (e.g. rice farmers), and is thought to result from inoculation, aspiration or inhalation and possibly ingestion It is probably more widespread in the tropics than is currently recognised, and several recent cases have been reported from the Indian sub-continent and the Caribbean. In NE Thailand, it is the commonest isolate from blood cultures during the rainy season in some hospitals. Exposure to the organism is common, but disease occurs particularly in the immunocompromised (e.g. diabetics). Although the incubation period is usually relatively short, it may remain latent for up to 30 years. Melioidosis has a broad spectrum of clinical manifestations. 60% of cases are bacteraemic, presenting with community-acquired sepsis syndrome with high mortality, although some have a more ‘typhoidal’ illness. Half have obvious primary focus, usually in the lungs, skin or soft tissue. Metastatic abscesses are common, especially in the lung, liver, spleen, kidney, prostate, and skin or soft tissue. The other 40% have localised infections, again in any organ, particularly the lung, liver and spleen in adults, or these sites plus the parotid in children. Chronic foci often become granulomatous.
Between 1 and 6 cases have been diagnosed annually in England and Wales over the past ten years, most originating from the Indian sub-continent. The diagnosis should be considered in anyone who has ever lived in endemic area presenting with sepsis and/or abscesses, especially diabetics. The organism is easy to culture from sterile sites (e.g. blood, pus, and urine), but selective media increase the isolation rate from sputum, swabs etc. Serological tests are available, but have relatively poor specificity and sensitivity.
Treatment involves supportive measures, including drainage of abscesses, and prolonged antibiotic therapy. The organism is intrinsically resistant to many antibiotics, including penicillin and aminoglycosides. New beta-lactams such as ceftazidime and imipenem given for 2 weeks substantially reduce mortality rates, but must be followed by long courses (20 weeks) of oral agents in order to prevent relapse.
Is it Safe to Bury your Head in the Sand?
Prof F J Bolton, Preston
The safety of bathing beaches is assessed according to the criteria specified in the EC Directive (76/160/EEC). This primarily assesses the microbiological quality of bathing water. There is no requirement to determine the levels, frequency and range of enteric pathogens which may be present. Risk of acquiring infections has mainly been associated with bathing in contaminated water. The risk associated with contaminated sand on bathing beaches is unknown.
Over the last few years several studies have been undertaken at the Preston Public Health Laboratory to determine the prevalence of Salmonella and Campylobacter in sand on bathing beaches. This presentation will concentrate on three studies, which were conduced between 1991 and 1997.
In the first of the three studies in the early 1990’s a large beach which was not designated as a bathing beach according to the EEC Directive was sampled between January 1991 and January 1994. During this study samples of sand were collected from the main body of the beach (dry sand) and from a point close to the waters edge (wet sand). In this study 22% of samples were positive for Salmonella and 46% for Campylobacters. There did not appear to be any great seasonal variation in contamination rates and E. coli counts of sand were not predictive of the presence of enteric pathogens.
The second study was undertaken in late 1994 and was designed to investigate differences in the presence of enteric pathogens in sand from EEC designated beaches and from non-EEC beaches. These studies were part of a joint collaboration with the Exeter Public Health Laboratory and therefore beaches in the North West and South West of England were sampled. This study and a subsequent study in 1996 have confirmed our original observations that bathing beaches are frequently contaminated with enteric pathogens. In these latter two studies the relationship between the designation of beaches and the geographical location have been investigated. Salmonella and Campylobacter isolates have been fully characterised and it is clear that types associated with human infections are frequently found in sand on beaches used by the general public. The results of these two studies will be presented in detail and the possible significance of these organisms discussed.
A major challenge for bathing beaches is to ensure that they do not pose a threat to bathers and the beach residents. The difficult question is – Do we really understand the risk associated with bathing beaches or have we buried our heads in the sand?
MRSA – is it time to stop screening?
Dr B Cookson,London
Jevons described heterogeneous resistant methicillin-resistant Staphylococcus aureus (MRSA) in 1961 shortly after methicillin was used clinically. Discussions regarding their clinical relevance have waxed and waned over the last 40 years. The arguments against continuing screening have included: MRSA respond to methicillin clinically, the lack of virulence or clinical significance, that they are now endemic, occurring with increasing frequency even in the community or that they are the modern-day penicillin-resistant Staphylococcus aureus. I will paint on a historical backcloth when discussing these issues.
There were no formal national surveillance schemes in the UK in the 1960s or ‘70s. The UK was proud of its hospital alert organism surveillance system and the general consensus was that MRSA occurrence decreased during the 1970s, perhaps due to gentamicin introduction or improved infection control, but re-emerged as gentamicin-resistant MRSA in the ‘80s. Other countries experiences’ were similar, but differed in time-scales and strain types.
Dr Marples and others carried out many pioneering UK studies. It quickly emerged that the epidemiology had to be related to the types of MRSA. “Epidemic” MRSA (EMRSA) were defined, clinical behaviour ascertained and numbered. EMRSA-1 was indistinguishable from some Eastern Australian EMRSA, E-2 to E-16 were unique to the UK, but some have since spread internationally. Gentamicin resistant strains have decreased over time in the UK and isolates in general have been susceptible to several other antimicrobial agents. However, more recently a highly resistant EMRSA-17 strain has emerged, some isolates of which are now also moderately resistant to teicoplanin. Studies of virulence and epidemicity MRSA factors show variation in toxic gene presence and other possible virulence factors such as hydrophobicity. This may indicate a “shock” environment around the organisms and that host factors, as one would suspect, are likely to be important regarding susceptibility to infection.
UK MRSA surveillance has included data from the typing laboratory, voluntary strain reporting, the bacteraemia reporting system, questionnaire surveys and the national prevalence surveys. EMRSA types have waxed and waned in the 1980s and ‘90s, other strains spread in Northern Europe. E-16 has uniquely been followed from the initial hospital to all parts of the country. Resistance to mupirocin, perhaps the most effective MRSA antiseptic was described soon after clinical use and is now prevalent: its genetics and epidemiology are complex.
All the sources of data over the last 10y indicate that MRSA are a significant cause of UK hospital acquired infections. Surveys and retrospective studies have examined the current success of E-15 and -16 and related these to changes in healthcare delivery, demography and case mix. Many hospital admissions are from affected nursing homes. In the late 1990s the PHLS surveillance data have been augmented with a more structured surveillance schemes. These comprised the clinical audit project and more recently the national surveillance system.
Genuine community, i.e. non nosocomial, infections described rarely elsewhere are not yet seen in significant numbers. Perhaps this will be the next phase: I hope not!
The debate continues, but my opinion remains that the data shown in this lecture illustrate that MRSA are a significant cause of hospital acquired infection. It is essential that we design screening strategies to determine MRSA acquisitions, which should be an important quality of care (and hospital performance) indicator. Such data are very useful surrogate markers of cross-infection. Feed-back of MRSA acquisitions will inform handhygiene, environmental and other aspects of infection control continuous improvement programmes. Such strategies are being introduced in many countries and new MRSA acquisitions are being reduced. Such strategies enable patients to be reassured that everything possible has been done to prevent them acquiring MRSA following their admission to these hospitals.
An Evaluation of a New Chromogenic Medium for the Detection of Urinary Tract Pathogens (POSTER)
Lynne A. Butterworth, Julie Clarke, John D. Perry and Kate Gould,
Newcastle upon Tyne, UK
We report the evaluation of a new chromogenic agar medium, Harlequin CLED medium, for the isolation and differentiation of urinary tract pathogens. 1100 urine samples were cultured in duplicate onto three different media:
Harlequin CLED, CPS ID 2 medium and traditional CLED agar. 260 urine samples (23.6 %) yielded a significant growth of bacteria defined as > 50000 cfu/ml and a total of 369 bacterial strains were recovered at a count above this threshold. Of these, 357 (96.7 %) were recovered on Harlequin CLED medium, 350 (94.9 %) were recovered on CPS ID 2 and 320 (86.7 %) were recovered on traditional CLED. This study confirmed the utility of chromogenic media for the differentiation of mixed cultures. Both Harlequin CLED and CPS ID 2 were highly specific for the identification of E.coli with specificities of 100 % and 98.4 % respectively. The ability of all three media to detect a range of urinary tract pathogens is presented and discussed.
The value of the Introduction of a Vitek Automated Identification and Susceptibility Testing System (POSTER)
R. Paton, Edinburgh
Background: Automated technology for antibiotic susceptibility testing in clinical bacteriology laboratories has become increasingly popular over the last decade. Integration of such technology into the UK has been minimal and only now has there been a slow uptake of automated systems by UK laboratories.
This report describes a year of experience with the Vitek system. The introduction of the Vitek necessitated several major changes to be made: A chromogenic urine medium was adopted as the base medium for our urine culture, centralisation of all susceptibility and identification tests and installation of a bi-directional computer interface. The transition from our previous manual methodology to the Vitek system went smoothly and for such a radical change in laboratory practice posed little problems.
Conclusions: The main benefit from the laboratory point of view was time saved in reading susceptibility results and upload of results directly to the laboratory information system from the BCI link. The expert software was particularly impressive and was invaluable as a learning tool for laboratory staff. We had confidence in the results, and with the aid of the expert software and identification to species level of all coliforms we are now taking intrinsic resistance mechanisms seriously. In our experience, although specific costs have risen by 55% for susceptibility and identification, these costs have been largely offset by efficiencies in staffing. The introduction of the Vitek system has been a positive experience and that the added costs of such technology is justified by the overall technical and clinical benefits.
Antibacterial Activity of Essential Oils Against Acinetobacter spp and
Enterobacteriaceae (POSTER)
A Hancox, Leeds
The incidence of antibiotic resistance among Gram-negative organisms is increasing in the hospital environment. Organisms such as Acinetobacter spp and Enterobacteriaceae are often implicated in nosocomial infection. Essential oils and plants are well known for their antimicrobial activity and may provide a use in controlling nosocomial infection. This investigation involved screening Acinetobacter spp and strains of Enterobacteriaceae isolated from immunosuppressed patients using twenty five essential oils to assess the level of susceptibility using disc diffusion. The oils showing the highest level of antibacterial activity were then tested against a larger number of similar strains to assess their minimum inhibitory concentration. A time kill study was performed using an environmental strain of Acinetobacter baumanii isolated during a nosocomial outbreak. The in vitro studies proved that some essential oils are effective against organisms implicated in such outbreaks. Systematic approaches to methodology and investment in research and development into the use of essential oils as alternative therapies are required. Further work is needed to establish efficacy and safety issues.
An Evaluation of a new Chromogenic agar, Candida ID medium, for the isolation of Pathogenic Yeasts (POSTER)
John D. Perry, Gavin Riley, Graham R. Short and Katherine E.
Newcastle upon Tyne, UK
We report the evaluation of a new chromogenic agar medium for the selective isolation of pathogenic yeasts. This medium, Candida ID, is designed for the rapid detection of Candida albicans using a chromogenic enzyme substrate. Other Candida species may be distinguished from each other by a second chromogenic enzyme substrate. The medium was challenged with a wide range of clinical samples and compared with other commercially available media. From 339 clinical samples we recovered a total of 143 yeasts. Of these, 97.2 % were recovered on Candida ID medium, compared with 94.4 % on Chromagar Candida, 98.6 % on Albicans ID2 medium and 85.3 % on Sabouraud agar. Candida ID medium was also useful for the rapid confirmation of Candida albicans.
Clostridium difficile, Should we be Testing for Both Toxin A and B? (POSTER)
Tim Forster, Middlesex
Toxigenic Clostridium difficile is a major cause of antibiotic associated diarrhoea and colitis and is the causative agent for virtually all cases of pseudomembranous colitis.
Two immunochemically and biologically distinct toxins, toxin A and toxin B are associated with disease caused by C.difficile. Toxin A has been described as an enterotoxin and toxin B as a potent cytotoxin, it has been hypothesised that the two toxins may act synergistically in vivo.
This study attempts to evaluate a new EIA assay for the combined presence of both toxins A and B as compared to an assay for toxin A alone in hospital patients suffering from diarrhoea.
Evaluation of a New Oxoid Dryspot kit for the Detection of
Streptococcus pneumoniae from Blood Cultures (POSTER)
A.C.Parker, O.M. Sidnell, and T.D Hartman
Basingstoke
Objectives: To evaluate a new fast and simple latex agglutination test for the detection of Streptococcus pneumoniae from blood cultures.
Methods: The Oxoid Dryspot Pneumo kit consists of latex particles (sensitised with specific antibody and dried onto cards) which agglutinate with all the recognised serological types of S. pneumoniae to form visible clumps. 37 known serotypes of S. pneumoniae and 35 non-S. pneumoniae were grown in three blood culture systems and tested with the Oxoid Dryspot kit and two competitor kits.
Conclusions: The new Dryspot Pneumo kit is comparable to or better than Wellcogen and Slidex kits with excellent sensitivity and specificity to strains grown in different blood culture systems. The Dryspot kit has the advantage of room temperature storage for 2 years.
Improving the New Oxoid Legionella Dryspot Latex Agglutination Test by using a Low pH Buffer (POSTER)
Parker, A.C.;.Sidnell, O.M.; and Hartman, T.D., Hampshire
The Oxoid Legionella Dryspot kit is a new latex agglutination test for the identification of predominant Legionella species grown on plate media from patients with suspected Legionellosis or from environmental sources. The Dryspot reagents allow separate identification of Legionella pneumophila serogroup 1, serogroups 2-14 and detection of seven (7) other Legionella species that have been implicated in human disease. Direct latex agglutination reactions with Legionella are often stringy. Stringy reactions are difficult to interpret and may lead to misdiagnosis. The inclusion of a low pH buffer for suspending Legionella strains in the new Legionella Dryspot kit significantly reduces stringiness. This removes the ambiguity of diagnosis in direct tests. It is thought that stringiness is exacerbated by a high lipopolysaccharide (LPS) content in the cell walls of Legionella strains and that low pH (4.2) cleaves the lipid A from LPS resulting in reduced stringiness. The Dryspot kit has the additional benefit of two (2) years shelf-life at room temperature. The new Oxoid kit was evaluated with thirty-nine (39) strains grown on Oxoid culture medium containing four (4) different growth supplements (BCYE only, GVPC, BMPA and MWY). In addition, forty-five (45) strains, (grown on BCYE only) were used to further evaluate Legionella Dryspot. Legionella Dryspot gave comparable or better sensitivity, final agglutination strength and specificity to the Oxoid Legionella wet test (DR800M) and two competitor kits. The sensitivity and specificity of the Oxoid Dryspot test is 100 and 96.4 % respectively.
ABSTRACTS
Primary Care Groups
Why is our performance different?
What do we have to do to improve our performance?
2. Initial agreement on a standardised test nomenclature with sufficient sophistication to allow the data to generate useful relevant performance outputs.
3. Agreement on cost measurement techniques to enable comparability of cost drivers and cost elements.
4. Sufficient detailed benchmark information to enable reasons for variability in performance to be detected.
5. Robust processes to allow the benchmark(s) to be reviewed over time to monitor improvements and continue peer comparisons.
In addition, there has been ‘centralised’ approach to purchasing laboratory consumables. Wherever possible, quotations for the supply of goods have been based on the combined requirements of both laboratories, and discount structures have reflected this. Stocks of consumables are only normally held at one centre and supplied to the other as required. This has had the advantage of simplifying and conserving storage space. Similarly, low-use consumables have been purchased by just one of the laboratories, and supplied to the other as required, avoiding the need for both laboratories to discard unnecessary expired reagents.
2. Fenton KA, Rogers PA, Simms I, Maguire H, Catchpole M. Increasing
gonorrhoea reports-not only in London. Lancet; 335:1907.
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Although approximately 2% of normal healthy adults are colonised with C.difficile, many patients acquire this organism through nosocomial infection. Exposure to antibiotics is thought to allow proliferation of toxigenic C.difficile by disrupting the normal intestinal flora.
Although the presence of toxin B has a positive correlation to 90-100% of patients with severe disease, it requires cell culture capability and up to 72hrs incubation. Many laboratories only test for the presence of toxin A, using a variety of EIA systems.
