Now showing 1 - 10 of 80
  • Publication
    Case Reports
    Scrub typhus in the Northern Territory: exceeding the boundaries of Litchfield National Park.
    (2004) ;
    Raines M
    ;
    Whelan PI
    ;
    Scrub typhus is recognised as an important differential diagnosis of fever, rash and sepsis in patients with a history of travel to Litchfield National Park in the Top End of the Northern Territory. All confirmed scrub typhus cases to date from the Northern Territory have visited the Park, but the presence of similar rainforest pockets elsewhere in the Top End suggested further infectious locations might be identified with increased tourism. We report a case of serologically confirmed Orientia tsutsugamushi infection in a man who had not been within Litchfield Park, but had visited another discrete Top End rainforest area.
      1192
  • Publication
    Journal Article
    Severe Disseminated Gonococcal Infection with Polyarticular Gout: Two Cases in Older Travelers.
    (2018-11-19)
    Smith EL
    ;
    Hodgetts KE
    ;
    ;
    Two male travelers with histories of gout and hazardous alcohol consumption, presented with a triad of severe culture-positive disseminated gonococcal infection, crystal-positive polyarticular gout, and gonococcal soft tissue collections, following unprotected sexual contact in The Philippines. Both men initially attributed symptoms to gout, since their usual joints were affected, but clinical deterioration occurred with self-administration of anti-inflammatory agents alone. The clinical courses were severe and protracted, requiring aggressive management of infection with prolonged intravenous antimicrobials and repeated surgery, and prolonged anti-inflammatory agents for gout. Joint symptom onset in each case occurred within a week of sexual exposure in conjunction with hazardous alcohol ingestion. We speculate that acute dissemination of infection to previously damaged joints triggered polyarticular gout, with progressive infection, exacerbated by unopposed anti-inflammatory agents and delayed antibiotics. Disseminated gonococcal infection can occur with polyarticular gout and delays in recognition and treatment, including while traveling, can lead to severe disease from both.
      1285
  • Publication
    Case Reports
    Vibrio vulnificus and V. parahaemolyticus necrotising fasciitis in fishermen visiting an estuarine tropical northern Australian location.
    Three cases of severe necrotising fasciitis due to Vibrio vulnificus (two cases) and Vibrio parahaemolyticus (one case, fatal), have occurred in Caucasian tourists while fishing at a remote tropical northern Australian estuarine area. Infections were acquired over a 4-year period during the tourist fishing season (April to July 2000-2003), when water temperatures range from 23 to 30 degrees C. They are notable for their geographical clustering in the remote western aspect of the Gulf of Carpentaria, an area characterised by sedimentary stratiform zinc-lead-silver deposits and a major mining operation. Patients presented with classical bullous cellulitis with necrotising fasciitis, accompanied by severe sepsis. Underlying risk factors were identified in each patient; in one instance, previously unrecognised haemochromatosis was diagnosed. Likely reasons for Vibrio occurrence in this particular ecological niche are discussed.
      1201
  • Publication
    Journal Article
    Searching for a technology-driven acute rheumatic fever test: the START study protocol.
    (2021-09-15) ;
    Webb, Rachel
    ;
    Moreland, Nicole J
    ;
    McGregor, Reuben
    ;
    Bosco, Anthony
    ;
    Broadhurst, David
    ;
    Lassmann, Timo
    ;
    Barnett, Timothy C
    ;
    Benothman, Rym
    ;
    ;
    Remenyi, Bo
    ;
    Bennett, Julie
    ;
    Wilson, Nigel
    ;
    Mayo, Mark
    ;
    Pearson, Glenn
    ;
    Kollmann, Tobias
    ;
    Carapetis, Jonathan R
    INTRODUCTION: The absence of a diagnostic test for acute rheumatic fever (ARF) is a major impediment in managing this serious childhood condition. ARF is an autoimmune condition triggered by infection with group A Streptococcus. It is the precursor to rheumatic heart disease (RHD), a leading cause of health inequity and premature mortality for Indigenous peoples of Australia, New Zealand and internationally. METHODS AND ANALYSIS: 'Searching for a Technology-Driven Acute Rheumatic Fever Test' (START) is a biomarker discovery study that aims to detect and test a biomarker signature that distinguishes ARF cases from non-ARF, and use systems biology and serology to better understand ARF pathogenesis. Eligible participants with ARF diagnosed by an expert clinical panel according to the 2015 Revised Jones Criteria, aged 5-30 years, will be recruited from three hospitals in Australia and New Zealand. Age, sex and ethnicity-matched individuals who are healthy or have non-ARF acute diagnoses or RHD, will be recruited as controls. In the discovery cohort, blood samples collected at baseline, and during convalescence in a subset, will be interrogated by comprehensive profiling to generate possible diagnostic biomarker signatures. A biomarker validation cohort will subsequently be used to test promising combinations of biomarkers. By defining the first biomarker signatures able to discriminate between ARF and other clinical conditions, the START study has the potential to transform the approach to ARF diagnosis and RHD prevention. ETHICS AND DISSEMINATION: The study has approval from the Northern Territory Department of Health and Menzies School of Health Research ethics committee and the New Zealand Health and Disability Ethics Committee. It will be conducted according to ethical standards for research involving Indigenous Australians and New Zealand Māori and Pacific Peoples. Indigenous investigators and governance groups will provide oversight of study processes and advise on cultural matters.
      1948
  • Publication
    Journal Article
    Improving Delivery of Secondary Prophylaxis for Rheumatic Heart Disease in a High-Burden Setting: Outcome of a Stepped-Wedge, Community, Randomized Trial.
    (2018-07-17) ;
    de Dassel JL
    ;
    Kirby A
    ;
    Read C
    ;
    Mitchell AG
    ;
    Maguire GP
    ;
    ;
    Bailie RS
    ;
    Johnston V
    ;
    Carapetis JR
    Health system strengthening is needed to improve delivery of secondary prophylaxis against rheumatic heart disease. We undertook a stepped-wedge, randomized trial in northern Australia. Five pairs of Indigenous community clinics entered the study at 3-month steps. Study phases comprised a 12 month baseline phase, 3 month transition phase, 12 month intensive phase and a 3- to 12-month maintenance phase. Clinics received a multicomponent intervention supporting activities to improve penicillin delivery, aligned with the chronic care model, with continuous quality-improvement feedback on adherence. The primary outcome was the proportion receiving ≥80% of scheduled penicillin injections. Secondary outcomes included "days at risk" of acute rheumatic fever recurrence related to late penicillin and acute rheumatic fever recurrence rates. Overall, 304 patients requiring prophylaxis were eligible. The proportion receiving ≥80% of scheduled injections during baseline was 141 of 304 (46%)-higher than anticipated. No effect attributable to the study was evident: in the intensive phase, 126 of 304 (41%) received ≥80% of scheduled injections (odds ratio compared with baseline: 0.78; 95% confidence interval, 0.54-1.11). There was modest improvement in the maintenance phase among high-adhering patients (43% received ≥90% of injections versus 30% [baseline] and 28% [intensive], P<0.001). Also, the proportion of days at risk in the whole cohort decreased in the maintenance phase (0.28 versus 0.32 [baseline] and 0.34 [intensive], P=0.001). Acute rheumatic fever recurrence rates did not differ between study sites during the intensive phase and the whole jurisdiction (3.0 versus 3.5 recurrences per 100 patient-years, P=0.65). This strategy did not improve adherence to rheumatic heart disease secondary prophylaxis within the study time frame. Longer term primary care strengthening strategies are needed. URL: www.anzctr.org.au. Unique identifier: ACTRN12613000223730.
      1239
  • Publication
    Journal Article
    Combination of Vancomycin and β-Lactam Therapy for Methicillin-Resistant Staphylococcus aureus Bacteremia: A Pilot Multicenter Randomized Controlled Trial.
    (2016-01-15)
    Davis JS
    ;
    Sud A
    ;
    O'Sullivan MVN
    ;
    Robinson JO
    ;
    Ferguson PE
    ;
    Foo H
    ;
    van Hal SJ
    ;
    ;
    Howden BP
    ;
    Binks PM
    ;
    Kirby A
    ;
    Tong SYC
    ;
    Majumdar S
    ;
    ;
    Gordon C
    ;
    Jeremiah C
    ;
    Leung G
    ;
    Brischetto A
    ;
    Crowe A
    ;
    Dakh F
    ;
    Whykes K
    ;
    Kirkwood M
    ;
    Menon M
    ;
    Somerville L
    ;
    Subedi S
    ;
    Owen S
    ;
    Liu E
    ;
    Zhou F
    ;
    Robinson O
    ;
    Coombs G
    ;
    Pollet S
    ;
    Davis R
    In vitro laboratory and animal studies demonstrate a synergistic role for the combination of vancomycin and antistaphylococcal β-lactams for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. Prospective clinical data are lacking. In this open-label, multicenter, clinical trial, adults with MRSA bacteremia received vancomycin 1.5 g intravenously twice daily and were randomly assigned (1:1) to receive intravenous flucloxacillin 2 g every 6 hours for 7 days (combination group) or no additional therapy (standard therapy group). Participants were stratified by hospital and randomized in permuted blocks of variable size. Randomization codes were kept in sealed, sequentially numbered, opaque envelopes. The primary outcome was the duration of MRSA bacteremia in days. We randomly assigned 60 patients to receive vancomycin (n = 29), or vancomycin plus flucloxacillin (n = 31). The mean duration of bacteremia was 3.00 days in the standard therapy group and 1.94 days in the combination group. According to a negative binomial model, the mean time to resolution of bacteremia in the combination group was 65% (95% confidence interval, 41%-102%; P = .06) that in the standard therapy group. There was no difference in the secondary end points of 28- and 90-day mortality, metastatic infection, nephrotoxicity, or hepatotoxicity. Combining an antistaphylococcal β-lactam with vancomycin may shorten the duration of MRSA bacteremia. Further trials with a larger sample size and objective clinically relevant end points are warranted. Australian New Zealand Clinical Trials Registry: ACTRN12610000940077 (www.anzctr.org.au).
      1546
  • Publication
    Journal Article
    Community-acquired methicillin-resistant Staphylococcus aureus in Central Australia.
    (2006-12)
    Stevens, Claire L
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    ;
    McLeod, James E T
    ;
    McDonald, Malcolm I
    To date, there has been scant information about the burden of methicillin-resistant Staphylococcus aureus infections in Central Australia. Our aims were to determine the proportion of Staphylococcus aureus infections due to methicillin-resistant strains in Central Australia, to characterise resistance to non-beta lactam antibiotics and to correlate findings with available demographic information. We retrospectively reviewed S. aureus isolates identified by the Microbiology Laboratory of the Pathology Department, Alice Springs Hospital between September 2005 and February 2006. Multi-resistance was defined as resistance to three or more non-beta lactam antibiotics. We identified the recovery site and extended antibiotic resistance profile of each isolate. Demographic data included place of residence, discharge diagnosis and ethnicity. There were 524 S. aureus isolates: 417 (79.6%) methicillin-sensitive S. aureus, 104 (19.7%) non-multi-resistant MRSA (nmrMRSA) and 3 (0.7%) multi-resistant MRSA (mrMRSA). MRSA accounted for 7/22 (32%) invasive infections and 91/474 (19.2%) cases of staphylococcal skin infections. Aboriginal people comprised 89 per cent (93/104) of patients with nmrMRSA; 57 per cent lived in remote communities, 21 per cent in suburban Alice Springs, and 18 per cent in Alice Springs Town Camps. Six per cent (6/104) of nmrMRSA were hospital-acquired. Of the nmrMRSA isolates, 57 per cent (59/104) were resistant to erythromycin and 7 per cent (7/104) to fusidic acid. All MRSA isolates were susceptible to co-trimoxazole. In conclusion, Central Australia has high rates of community-acquired nmrMRSA and low rates of multi-resistant MRSA. Erythromycin resistance in S. aureus is also common. These findings should prompt the review of antimicrobial prescribing guidelines for the region, especially for treatment of skin and soft tissue infections.
      349
  • Publication
    Journal Article
    "The talking bit of medicine, that's the most important bit": doctors and Aboriginal interpreters collaborate to transform culturally competent hospital care.
    (2021-07-23)
    Kerrigan V
    ;
    McGrath SY
    ;
    ;
    Walker M
    ;
    Ahmat M
    ;
    Lee B
    ;
    Cass A
    ;
    Hefler M
    ;
    BACKGROUND: In hospitals globally, patient centred communication is difficult to practice, and interpreters are underused. Low uptake of interpreters is commonly attributed to limited interpreter availability, time constraints and that interpreter-medicated communication in healthcare is an aberration. In Australia's Northern Territory at Royal Darwin Hospital, it is estimated around 50% of Aboriginal patients would benefit from an interpreter, yet approximately 17% get access. Recognising this contributes to a culturally unsafe system, Royal Darwin Hospital and the NT Aboriginal Interpreter Service embedded interpreters in a renal team during medical ward rounds for 4 weeks in 2019. This paper explores the attitudinal and behavioural changes that occurred amongst non-Indigenous doctors and Aboriginal language interpreters during the pilot. METHODS: This pilot was part of a larger Participatory Action Research study examining strategies to achieve culturally safe communication at Royal Darwin Hospital. Two Yolŋu and two Tiwi language interpreters were embedded in a team of renal doctors. Data sources included interviews with doctors, interpreters, and an interpreter trainer; reflective journals by doctors; and researcher field notes. Inductive thematic analysis, guided by critical theory, was conducted. RESULTS: Before the pilot, frustrated doctors unable to communicate effectively with Aboriginal language speaking patients acknowledged their personal limitations and criticised hospital systems that prioritized perceived efficiency over interpreter access. During the pilot, knowledge of Aboriginal cultures improved and doctors adapted their work routines including lengthening the duration of bed side consults. Furthermore, attitudes towards culturally safe communication in the hospital changed: doctors recognised the limitations of clinically focussed communication and began prioritising patient needs and interpreters who previously felt unwelcome within the hospital reported feeling valued as skilled professionals. Despite these benefits, resistance to interpreter use remained amongst some members of the multi-disciplinary team. CONCLUSIONS: Embedding Aboriginal interpreters in a hospital renal team which services predominantly Aboriginal peoples resulted in the delivery of culturally competent care. By working with interpreters, non-Indigenous doctors were prompted to reflect on their attitudes which deepened their critical consciousness resulting in behaviour change. Scale up of learnings from this pilot to broader implementation in the health service is the current focus of ongoing implementation research.
      1589
  • Publication
    Journal Article
    The Darwin Prospective Melioidosis Study: a 30-year prospective, observational investigation.
    (2021-12) ;
    Mayo M
    ;
    Ward LM
    ;
    Kaestli M
    ;
    ;
    Webb JR
    ;
    Woerle C
    ;
    ; ; ; ; ; ;
    Huffam SE
    ;
    Janson S
    ;
    ; ; ;
    BACKGROUND: The global distribution of melioidosis is under considerable scrutiny, with both unmasking of endemic disease in African and Pacific nations and evidence of more recent dispersal in the Americas. Because of the high incidence of disease in tropical northern Australia, The Darwin Prospective Melioidosis Study commenced in October, 1989. We present epidemiology, clinical features, outcomes, and bacterial genomics from this 30-year study, highlighting changes in the past decade. METHODS: The present study was a prospective analysis of epidemiological, clinical, and laboratory data for all culture-confirmed melioidosis cases from the tropical Northern Territory of Australia from Oct 1, 1989, until Sept 30, 2019. Cases were identified on the basis of culture-confirmed melioidosis, a laboratory-notifiable disease in the Northern Territory of Australia. Patients who were culture-positive were included in the study. Multivariable analysis determined predictors of clinical presentations and outcome. Incidence, survival, and cluster analyses were facilitated by population and rainfall data and genotyping of Burkholderia pseudomallei, including multilocus sequence typing and whole-genome sequencing. FINDINGS: There were 1148 individuals with culture-confirmed melioidosis, of whom 133 (12%) died. Median age was 50 years (IQR 38-60), 48 (4%) study participants were children younger than 15 years of age, 721 (63%) were male individuals, and 600 (52%) Indigenous Australians. All but 186 (16%) had clinical risk factors, 513 (45%) had diabetes, and 455 (40%) hazardous alcohol use. Only three (2%) of 133 fatalities had no identified risk. Pneumonia was the most common presentation occurring in 595 (52%) patients. Bacteraemia occurred in 633 (56%) of 1135 patients, septic shock in 240 (21%) patients, and 180 (16%) patients required mechanical ventilation. Cases correlated with rainfall, with 80% of infections occurring during the wet season (November to April). Median annual incidence was 20·5 cases per 100 000 people; the highest annual incidence in Indigenous Australians was 103·6 per 100 000 in 2011-12. Over the 30 years, annual incidences increased, as did the proportion of patients with diabetes, although mortality decreased to 17 (6%) of 278 patients over the past 5 years. Genotyping of B pseudomallei confirmed case clusters linked to environmental sources and defined evolving and new sequence types. INTERPRETATION: Melioidosis is an opportunistic infection with a diverse spectrum of clinical presentations and severity. With early diagnosis, specific antimicrobial therapy, and state-of-the-art intensive care, mortality can be reduced to less than 10%. However, mortality remains much higher in the many endemic regions where health resources remain scarce. Genotyping of B pseudomallei informs evolving local and global epidemiology. FUNDING: The Australian National Health and Medical Research Council.
      2062
  • Publication
    Journal Article
    Mortality attributable to Plasmodium vivax malaria: a clinical audit from Papua, Indonesia.
    (2014-11-18)
    Douglas NM
    ;
    Pontororing GJ
    ;
    Lampah DA
    ;
    Yeo TW
    ;
    Kenangalem E
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    Poespoprodjo JR
    ;
    ;
    Bangs MJ
    ;
    Sugiarto P
    ;
    ;
    Plasmodium vivax causes almost half of all malaria cases in Asia and is recognised as a significant cause of morbidity. In recent years it has been associated with severe and fatal disease. The extent to which P. vivax contributes to death is not known. To define the epidemiology of mortality attributable to vivax malaria in southern Papua, Indonesia, a retrospective clinical records-based audit was conducted of all deaths in patients with vivax malaria at a tertiary referral hospital. Between January 2004 and September 2009, hospital surveillance identified 3,495 inpatients with P. vivax monoinfection and 65 (1.9%) patients who subsequently died. Charts for 54 of these 65 patients could be reviewed, 40 (74%) of whom had pure P. vivax infections on cross-checking. Using pre-defined conservative criteria, vivax malaria was the primary cause of death in 6 cases, a major contributor in 17 cases and a minor contributor in a further 13 cases. Extreme anaemia was the most common primary cause of death. Malnutrition, sepsis with respiratory and gastrointestinal manifestations, and chronic diseases were the commonest attributed causes of death for patients in the latter two categories. There were an estimated 293,763 cases of pure P. vivax infection in the community during the study period giving an overall minimum case fatality of 0.12 per 1,000 infections. The corresponding case fatality in hospitalised patients was 10.3 per 1,000 infections. Although uncommonly directly fatal, vivax malaria is an important indirect cause of death in southern Papua in patients with malnutrition, sepsis syndrome and chronic diseases, including HIV infection.
      1321