Australasian Society for Infectious

Diseases (ASID) Limited

Conference

Handbook

ASID New Zealand Annual Meeting

Organising Committee: Dr James Ussher, Dr Antje van der Linden, Dr Brendan Arnold, Ms Fiona

Gray and the organisers of the Otago Global Health Institute conference held prior to the ASID

Annual Meeting.

ASID Secretariat: Marilena Salvo, Senior Executive Officer

Venue: Otago Daily Times Gallery and Conference Room

Dunedin Public Art Gallery

30 the Octagon, Dunedin

Venue Contact: Dana Lee 03 474 3269

ASID staff on site: Marilena Salvo, executive@asid.net.au

Parking: http://dunedin.art.museum/planning_a_visit

Website: https://www.asid.net.au/groups/nz-annual-meeting

Registration opens: Thursday 29 November 5pm

Twitter hashtag: Join the conversation at #asidnz18

Full Registrations include attendance to the Conference Dinner on Friday:

Venue: Dunedin Railways and Fleurs Place

Time: 5pm – 10.30pm

Dinner dress: Smart Casual

Your dinner experience begins at 5pm at Dunedin Railway station. A train will take you from

Dunedin to Fleurs Place so you can sit back and enjoy the amazing scenery. After an amazing

meal at Fleurs Place you will take a bus back to Dunedin Railway station.

Please ensure you are at the Railway Station no later than 4.50pm so you don’t miss the train.

Thank you to our sponsors:

Silver sponsor Dinner Spons

International Keynote Speaker – Professor Nick Day

Name Nicholas Philip John DAY Address Mahidol-Oxford Tropical Medicine Research Unit (MORU)

Faculty of Tropical Medicine, Mahidol University Email nickd@tropmedres.ac Education/Qualifications 2008 FMedSci 2003 FRCP(UK) 2002 DM, Oxford University 1999 CCST in Tropical Medicine, Infectious Diseases and General Internal Medicine 1989. MRCP(UK) 1986 BM, BCh, New College, University of Oxford, UK 1983 BA(Hons) in Physical Anthropology, Trinity College, Cambridge University, UK.

Current positions

1/03 Director, Thailand/Laos Wellcome Trust Major Overseas Programme and the Mahidol -Oxford Tropical Medicine Research Unit, Thailand.

5/99 Honorary Consultant in General Medicine and Infectious Diseases, Oxford University Hospitals NHS Trust 6/05 Visiting Professor, Faculty of Tropical Medicine, Mahidol University, Thailand 10/06 Professor of Tropical Medicine, University of Oxford 08/09 Visiting professor, Shantou University, China

Summary of research career

Nick joined the University of Oxford in 1991 as the director of the Wellcome Trust Clinical Research Unit (now OUCRU) in Vietnam, where for 5 years he conducted clinical studies on mal aria, tetanus, diphtheria, dengue and typhoid. On return to the UK he studied staphylococcal disease as a Wellcome Trust Career Development Fellow (1997 to 2002), and was Deputy Director of the Centre for Tropical Medicine at Oxford from 1999 to 2003. Since 2003 he has been Director of the Wellcome Trust Thailand/Laos Major Overseas Programme (MOP), a 36 year old collaboration between the University of Oxford and the Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. In 2006 he was awarded the Chalmers Medal by the Royal Society for Tropical Medicine and Hygiene for contributions to tropical medicine research.

The Mahidol-Oxford Tropical Medicine Research Unit (MORU), which hosts the WT Thailand/Laos MOP, is a large and productive tropical research unit, employing over 700 staff, with a diverse research portfolio. MORU conducts clinical research on malaria, melioidosis, leptospirosis, rickettsial infections, influenza, dengue, tuberculosis and other communicable diseases afflicting populati ons in the tropics throughout Asia and beyond.

Although he is involved in setting the strategic direction of all of the Programme’s research, his personal major research interests are in the diagnosis, pathophysiology, treatment and prevention of malaria, rickettsial infections, leptospirosis, staphylococcal disease and melioidosis.

Map of the centre of Dunedin indicating the conference venue (Dunedin Public Art Gallery) and

the meeting point for the conference dinner (Railway Station).

The program can be accessed at this link. The version below is current at the time of printing

and is subject to change at short notice.

ASID New Zealand Meeting, 29 November - 1 December 2018

Program

(program current at 26 November and subject to change)

Thursday. 29 November Speaker

5.30pm-6.30pm Registration & Welcome drinks

6.30-6.35 Introduction and welcome

6.35-7.15 Rise of the Planet of the Primate Malarias Bruce Russell

7.15-8.00pm Session 1, Proffered papers: Antibiotic stewardship

7.15-7.30 Antimicrobial stewardship in the Pacific Islands Richard Everts

7.30-7.45 Diagnostic stewardship: putting up barriers or improving provision of care? Arlo Upton

7.45-8.00 Evaluation of a smartphone application for deivery of antibiotic guidelines Olivia Bupha-Intr

Friday, 30 November

8.40am - 8.45am Welcome

8.45am -9.45am Session 2, Plenary 2

Threats to malaria elimination in Southeast Asia Nick Day

9.45am -10.15am Session 3, Tuberculosis

9.45-10.15 Tuberculosis in Myanmar Htin Lin Aung

10.15-10.30 The molecular epidemiology of a MIRU-VNTR linked Mycobacterium tuberculosis cluster in New Zealand Veronica Playle

10.30am - 10.45am Morning tea

10.45-11.00 Diagnostic Performance of Pleural Fluid Adenosine Deaminase for Tuberculous Pleural Effusion in a Low-Incidence Setting Matt Blakiston

11.00-11.15 Vitamin D in active tuberculosis in New Zealand Kate Grimwade

Session 4, Vaccines

11.15-11.45 Salmonella Typhi congjugate vaccines John Crump

11.45-12.15 Neisseria menigitidis vaccines Peter McIntyre

12.15pm - 1.15pm Lunch

1.15pm - 2.15pm Session 5, ASID New Zealand Annual General Meeting (ASID members only) ASID NZ Committee

2.30pm-3.45pm Session 6, Proffered papers: Staphylococcus aureus

2.15-2.30 Staphylococcus aureus bacteriuria: a cohort study from Middlemore Hospital Chris Hopkins

2.30-2.45 Outcomes of early oral antibiotic switch in uncomplicated healthcare associated Staphlyococcus aureus bacteraemia: A Wellington experience Olivia Bupha-Intr

2.45-3.00 Staphylococcus aureus colonisation and its relationship with skin and soft tissue infection in New Zealand children Mark Hobbs

3:00pm-3.15pm Afternoon Tea

3.15pm-4.00pm Session 7, Proffered papers: AMR

3.15-3.30 Lung penetration and PK/PD attainment in pulmonary epithelial lining fluid (ELF) following administration of 3 g ceftolozane/tazobactam to ventilated, critically-ill patients Andree Hubber

3.30-3.45 An outbreak of carbapenemase-producing Enterobacterales among four patietns with severe burns at Middlemore Hosptial in 2018 Chris Hopkins

3.45-4.00 Molecular epidemiology of multi-drug resistant (MDR) Acinetobacter in New Zealand Matt Blakiston

5.00pm Conference Dinner, train leaves at 5pm

Saturday, 1 December

9.00am - 10.00am Session 8, Plenary 3

Scrub typhus – an old enemy re-emerges Nick Day

10.00am -10.40am Session 9, Invited speaker

10.00-10.20 The epidemiology of leprosy in Kiribati Steve Chambers

10.20-10.40 Introducing WGS into the clinic Scott Beatson

10.40am - 11.00am Morning Tea

11.00am - 12.30pm Session 11, Antibiotics

11.00-11.15 Timing of surgical antibiotic prophylaxis: Is there a “sweet spot” in the hour before knife to skin? Arthur Morris

11.15-11.30 Pine bark – what role as a source of Legionella longbeachae in Legionnaires’ disease Steve Chambers

11.30-11.45 TRIME study James Ussher

11.45-12.00 Exploring the Enterococcus ribosome as a target for antibiotic development Kurt Krause

12.00pm-12.30pm Session 10, Mixed growth

12.00-12.15 Pseudo-outbreak of Respiratory Syncytial Virus in a Level 3 Neonatal Intensive Care Unit at Wellington Regional Hospital Max Bloomfield

12.15-12.30 Sepsis assessment at the point of care Nigel Raymond

12.30-12.40 Trainee Award Presentation & Conference Close

12.40pm Lunch

Proffered Papers Abstracts

Diagnostic Performance of Pleural Fluid Adenosine Deaminase for Tuberculous Pleural Effusion in a Low-Incidence Setting

Matt Blakiston 1,4, Weldon Chiu 2, Conroy Wong 3 , Susan Morpeth1, Susan Taylor1

1Microbiology Department, Counties Manukau Health; 2Biochemistry Department, Counties Manukau

Health; 3Respiratory Department, Counties Manukau Health; 4Microbiology Department, Auckland

District Health Board

Background: Pleural fluid adenosine deaminase (pfADA) has been utilised as a biomarker for

Tuberculous pleural effusion. It has however been primarily evaluated in intermediate to high incidence

settings. Reported diagnostic performance thus has limited generalizability to low incidence settings;

where the nonspecific nature of pfADA results in a low PPV. Nonetheless, with a high NPV it may still

have utility. This study evaluated the diagnostic performance of pfADA, the pleural fluid lactate dehydrogenase (LD)/ADA ratio, and combinations of these two parameters in a low TB incidence setting.

Methods: This was a retrospective observational study of persons ³ 15 years old who had pfADA testing

performed at Counties Manukau Health between March 2008 and November 2014. The overall

discriminatory performance were assessed utilizing ROC curve analysis. The sensitivity, specificity, PPV,

and NPV were calculated for preselected pfADA thresholds. Multiparameter analysis including pfADA

and the LD/ADA ratio was also performed.

Results: The median pfADA in 57 TB pleural effusion episodes (58.1 U/L) was significantly higher than in

1,580 non-TB pleural effusions (11.4 U/L). The median LD/ADA ratio in TB pleural effusion (8.2) was

significantly lower than in non-TB pleural effusions (30.5). The pfADA and LD/ADA ratio AUCROC values

were 0.93 and 0.94 respectively. pfADA thresholds of ³ 15 and ³ 30 U/L demonstrated sensitivities of

100% and 93.0%, specificities of 62.7% and 87.3%, PPVs of 8.8% and 20.9%, and NPVs of 100% and

99.7% respectively. A combination of pfADA ³ 30 U/L and a LD/ADA ratio < 15 increased specificity and

PPV to 97.8% and 57.3%.

Conclusion: The primary value of pfADA in a low TB incidence setting is in utilization of its high NPV. Consideration of pfADA levels relative to LD can provide additional information.

Molecular epidemiology of multi-drug resistant (MDR) Acinetobacter in New Zealand

Matt Blakiston1, Mark Schultz2, Indira Basu1, Susan Ballard2, Deborah Williamson2, Sally Roberts1

1 Microbiology department, Auckland District Health Board; 2 Microbiological Diagnostic Unit Public Health Laboratory

Background: Clonal lineages of MDR Acinetobacter are spreading worldwide. In NZ sporadic cases are

increasingly reported. The presence of MDR Acinetobacter in the Francophone Pacific Islands has be en

reported since the early 2000’s and more recently has been identified in patients transferred to NZ from

Fiji and Samoa. Utilising WGS-based molecular epidemiology we aimed to contextualise local isolates

within the global epidemiology, establish the relationship between isolates, and explore potential routes of dissemination.

Methods: This study utilised isolates previously identified with an acquired OXAcarbapenemase gene

from culture collections at ADHB and ESR. Basic demographic and epidemiological information was

collected. Isolate genomes were sequenced using the Illumina MiSeq. MLST was determined in silico and

a core-genome maximum likelihood (ML) tree of ST2 isolates was created using RaxML.

Results: Thirty-three A. baumannii complex isolates with acquired OXA-carbapenemase genes were

identified from 32 individuals; including 31 A. baumannii sensu stricto. Twentyone (66%) had a history of

overseas hospitalisation; including 14 in Fiji or Samoa. Two additional cases were linked to nosocomial

transmission in NZ. Twenty-three (74%) A. baumannii isolates were ST2. The ST2 ML tree demonstrated

a closely related cluster of 12 isolates; ten had known links to hospitalisation in Fiji or Samoa. Five further unrelated MDR Acinetobacter were identified in patients previously hospitalised in Fiji.

Conclusion: The emergence of MDR Acinetobacter has concerning implications for hospitals in Pacific

Island nations and NZ. A ST2 clonal strain appears to have spread between hospitals in Fiji, Samoa, and

NZ. Data also suggests that this stain is only one of multiple introductions of MDR Acinetobacter into Pacific hospitals.

Pseudo-outbreak of Respiratory Syncytial Virus in a Level 3 Neonatal Intensive Care Unit at Wellington Regional Hospital

Max Bloomfield1, Henrietta Sushames2, Michelle Balm1

1. Infection Services, Capital & Coast District Health Board, Wellington, NZ 2. Infection Prevention and Control Service, Capital & Coast District Health Board, Wellington, NZ

Our IPC team were notified on 1 August 2018 of four infants who had tested positive for RSV over the

preceding ten days in our 36 bed NICU. Initial control measures were implemented. Over the following

five days a further 15 infants tested positive. The unit was closed to national admissions and regional

admissions were carefully reviewed. Some elective caesarean deliveries were deferred, and considerable difficulties were encountered with infant placement.

Initial epidemiological investigation revealed an apparent index case, with possible transmission to other

infants in the same room within an incubation period, and subsequent dissemination more widely in the

unit. However, during the course of the investigation it was noted that many of the infants were only

mildly symptomatic, or asymptomatic, which was inconsistent with neonatal RSV outbreaks described in

the literature. RSV testing at Wellington Southern Community Laboratories is performed using the Sofia

immunofluorescence instrument. PCR testing of a subset of positive samples was arranged, and was

negative for RSV. Further testing revealed all 19 Sofia positives to be false positives. The ‘outbreak’ was

declared closed on 8 August, and business returned to normal.

In this talk I will discuss our investigation into the laboratory errors, lessons learned and other perspectives gained from this pseudo-outbreak.

Evaluation of a smartphone application for delivery of antibiotic guidelines

Olivia Bupha-Intr, Chris Little, James Taylor, Maxim Bloomfield, David Foley, Michelle Balm, Emma

Henderson, Matthew Kelly, Juliet Elvy, Timothy Blackmore, Nigel Raymond, Rebecca Grainger, Mansour

Javaher, Ayesha Verrall

Antimicrobial resistance is an increasingly serious threat to global public health. Studies show a strong

link between antibiotic use and the development of resistance. A priority within the healthcare system is

the appropriate use of antibiotics. Up to date, region and institution-specific antibiotic guidelines are key

components in appropriate antibiotic prescribing.

The use of smartphone applications to increase accessibility to antibiotic guidelines is common globally.

We have created an app called Empiric which is a locally developed app designed as an easy to use,

decision support tool that can be used at the point of care. Empiric was provided free to all clinical staff within the Wellington region.

The aim of this evaluation is to assess the impact of the app on antimicrobial use. The study was

performed across three hospitals in the Wellington region over a six month time period (three months

pre intervention and three months post intervention). We employed a mixed methods study design with a pre and post implementation analysis.

The outcome measures chosen for this study were a) antimicrobial consumption of four target

antibiotics measured in defined daily doses (DDDs), b) appropriateness of antimicrobial prescribing

measured at quarterly point prevalence studies, c) awareness and self -reported usage of the antibiotic

guidelines measured by a questionnaire, and d) usability of the smartphone application measured with

the System Usability Scale (SUS).

We are awaiting the post implementation dataset before reporting the final results of this evaluation. This will be available in September.

Outcomes of early oral antibiotic switch in uncomplicated healthcare associated Staphylococcus aureus bacteraemia: A Wellington experience

Olivia Bupha-Intr, Max Bloomfield

Current guidelines for management of Staphylococcus aureus bacteraemia (SAB) recommend a

minimum of two weeks of intravenous therapy for uncomplicated bacteraemia. Early oral switch or

shorter duration therapy are not recommended based on lack of clinical evidence. Our local practice has

been to perform early oral switch on patients deemed at low risk of complications. Anecdotally this has

been associated with very low rates of relapse or other adverse outcomes.

The aim of this retrospective cohort study was to compare outcomes for patients with uncomplicated

healthcare associated SAB (HCA-SAB) according to whether they had early oral switch or not, and to

describe local practice with regards to duration of intravenous therapy. Patients with low risk HCA-SAB

were identified from our bloodstream infection (BSI) database. Patients were included in the early oral

switch cohort if they had their antibiotics switched to oral during the two weeks of treatment; and the intravenous cohort if they completed the two week course of treatment with intravenous antibiotics.

The primary outcome measure was occurrence of SAB related complication (recurrence of SAB or deep

infection and attributable mortality) within 90 days. Secondary outcome measures were complications

of intravenous therapy, length of hospital stay and incidence of adverse effects.

The results of this retrospective cohort study are currently being analysed and will be ready for presentation at ASID NZ.

Staphylococcus aureus colonisation and its relationship with skin and soft tissue infection in New Zealand children

Mark R. Hobbs, Cameron C. Grant, Mark G. Thomas, Sarah Berry, Susan M. B. Morton, Emma Marks,

Stephen R. Ritchie.

Background:

New Zealand children suffer from high rates of skin and soft tissue infection (SSTI). Staphylococcus

aureus colonisation is known to increase the risk of nosocomial infection. We aimed to determine whether S. aureus colonisation also increased the risk of community-onset SSTI.

Methods:

This study, performed within the Growing Up in New Zealand cohort, used interview and administrative

data, and bacterial culture results from nose, throat, and skin swabs collected at 4½ years of age. Multivariable log-binomial regression was used to derive adjusted risk ratios.

Results:

S. aureus was isolated from 2225/5126 (43.4%) children. SSTI affected 1509/5126 (29.4%) children

before age five. S. aureus colonisation at any site was associated with SSTI (aRR=1.09, 95%CI 1.01–1.19),

particularly in the year prior to swab collection (aRR=1.18, 95%CI 1.02–1.37). The strongest association

was between skin colonisation and SSTI within the year prior to swab collection (aRR=1.47, 95%CI 1.14–1.84). Socioeconomic and ethnic variables remained independent determinants of SSTI.

Conclusions:

S. aureus colonisation was associated with an increased risk of community-onset SSTI. Socioeconomic

and ethnic factors, and eczema, had independent effects on SSTI risk. Interventions which reduce the

prevalence of S. aureus colonisation may be expected to reduce the incidence of community-onset SSTI.

Staphylococcus aureus bacteriuria: a cohort study from Middlemore Hospital

Authors block:

Susan Morpeth, ID Physician & Clinical Microbiologist1 Tom Hills, ID Registrar1 Niall Hamilton, Microbiology Registrar1 Chris Hopkins, ID Physician1 Susan Taylor, Clinical Microbiologist1 Steve McBride, ID Physician1 Chris Luey, ID Physician1 Genevieve Walls, ID Physician1 Michael Borrie, ID Physician1 David Holland, ID Physician1

1. Middlemore Hospital, Auckland

Background:

Staphylococcus aureus (SA) bacteriuria is thought to be an uncommon indication of urinary tract infection, but may indicate bacteraemia and/or invasive infection.

Methods:

Retrospective cohort study of SA bacteriuria between July 2015 and July 2017.

Results:

222 cases of SA bacteriuria were identified. 22/222 (10%) had documented dysuria and 62/222 (28%)

had urethral instrumentation in the past month. 110/222 (50%) had no blood cultures collected within 7

days either side of the urine. 49/222 (22%) had blood cultures collected the same day or within a week

prior to the urine collection (14/49 [29%] were positive), and 88/222 (40%) had blood cultures collected

within a week after the urine collection (16/88 [18%] were positive). 67/217 (31% ) were thought to

either have SA disease at the time of bacteriuria or within the following 6 months; 12 of these cases

were skin and soft tissue and 26 were invasive SA disease. In a multi -variable analysis, only pure urine

culture growth of SA remained significantly-associated with invasive or soft tissue SA disease, OR 2.95 (95% CI 1.25-6.96, p=0.013).

Conclusions:

SA bacteriuria commonly indicated the presence and/or risk of invasive SA infection. A pure growth of SA was associated with invasive or distant SA disease.

An Outbreak of Carbapenemase-Producing Enterobacterales Among Four Patients with Severe Burns at Middlemore Hospital in 2018.

Presenter: Dr Chris Hopkins, ID Physician, Middlemore Hospital

Authors:

Chris Hopkins, ID Physician1 Susan Morpeth, ID Physician & Clinical Microbiologist1 Susan Taylor, Clinical Microbiologist1 Steve McBride, ID Physician1 Chris Luey, ID Physician1 Terry Rings, Operations Manager, Infection Prevention & Control 1 Elizabeth Bryce, Clinical Nurse Specialist, Infection Prevention & Control1 Rachael Hart, Clinical Nurse Specialist, Infection Prevention & Control 1 Richard Wong-She, Plastic Surgeon1 Rachel Webb, ID Paediatrician1 Amanda Taylor, Paediatric ID Registrar1 Una Ren, Senior Scientist2 Helen Heffernan, Senior Scientist2 Jenny Draper, Senior Scientist2 David Holland, ID Physician1

1. Middlemore Hospital, Auckland 2. Institute of Environmental Science and Research Limited (ESR), Porirua

Abstract: In December 2017 a patient was transferred from an overseas hospital to the National Burns

Centre at Middlemore Hospital, and on admission had bacteraemia with New Delhi

Metallobetalactamase (NDM)-producing Providencia stuartii. Subsequently two further patients under

the care of the Burns service developed infections with NDM-producing organisms. All three patients

were successfully treated for several episodes of bacteraemia each, including with emerging antibiotic

agents, and eventually discharged. An extensive infection control investigation did not find evidence of

a mode of transmission, although multiple areas for improvement were identified. Several months after

all three patients had been discharged, a further case of colonisation with an NDM-producing organism

was identified in a Burns patient and in the sink of their hospital room. Results of whole genome

sequencing confirmed that isolates from all four patients and the environment sample were linked. We

present a summary of our management of the four cases and our outbreak response.

Lung penetration and PK/PD attainment in pulmonary epithelial lining fluid (ELF) following

administration of 3 g ceftolozane/tazobactam to ventilated, critically-ill patients

Luzelena Caro1 , Kajal Larson1 , David Nicolau2 , Jan De Waele3 , Joseph Kuti2, Elaine Gadzicki1 ,

Adedayo Adedoyin1 , Zhen Zeng1 , Elizabeth Rhee*1

1Merck & Co., Inc., Kenilworth, United States, 2Hartford Hospital, Hartford, United States, 3Ghent

University Hospital Belgium, Belgium

Background: Ceftolozane/tazobactam is approved for cIAI/cUTI in adults at 1.5g q8h and is being

studied at 3g q8h for ventilated nosocomial pneumonia. Here we present ceftolozane/tazobactam lung

penetration data from an open-label, multicentre, phase 1 study of 3g ceftolozane/tazobactam in

critically-ill, mechanically ventilated patients with proven/suspected pneumonia.

Methods: Patients received 4-6 doses of 3g ceftolozane/tazobactam q8h, adjusted for renal function.

Serial plasma and bronchoalveolar lavage samples were analysed for ceftolozane and tazobactam

concentrations in plasma and ELF. PK parameters were determined by non-compartmental analysis.

Target attainment was assessed by determining if the mean PK profiles achieved relevant PK/PD targets

(ceftolozane concentrations >8 μg/mL for ≥30% and tazobactam concentrations >1 μg/mL for ≥20% of

the dosing interval).

Results: Twenty-six patients received ≥1 dose of study drug. Lung penetration (ratio of mean unbound

area under the concentration-time curve in ELF to plasma) was 50% (ceftolozane) and 62%

(tazobactam). In ELF, pooled, mean ceftolozane concentrations remained >8 μg/mL and mean

tazobactam ELF concentrations >1 μg/mL for 100% of the dosing interval. There were no deaths or

adverse event-related discontinuations.

Conclusions: In ventilated pneumonia patients, 3g ceftolozane/tazobactam q8h provides adequate

plasma and pulmonary ELF exposure against pathogens with ceftolozane/tazobactam minimum

inhibitory concentrations ≤8 µg/mL.

Vitamin D deficiency in active Tuberculosis in New Zealand Kate Grimwade Introduction Vitamin D deficiency can play a key role in the reactivation of Tuberculosis, as established through the understanding of the cellular pathways and as demonstrated though epidemiological studies. In New Zealand, dark skinned people who have migrated from more sun exposed countries are at the greatest risk of developing vitamin D deficiency. These are the same population in which there are the highe st rates of active Tuberculosis. Testing for or treating vitamin D deficiency is not currently part of diagnostic and treatment pathways for new cases of TB. Method Physicians diagnosing and treating individuals with TB were surveyed on their current practice with respect to vitamin D testing and replacement. Results The findings of this work will be presented at the meeting. Conclusion The current New Zealand practice will be discussed in the context of the available evidence around the place of Vitamin D management in the wider care package for those with active TB.

Exploring the Enterococcus Ribosome as a target for antibiotic development

Kurt L. Krause MD, PhD

Department of Biochemistry, University of Otago, School of Biomedical Sciences,

Dunedin, New Zealand

Ribosomes are an important target for a wide variety of antibiotics. Increasingly, through the expediting

technology of cryo-electron microscopy, ribosome structures from pathogenic bacteria are being

explored as templates for antibiotic discovery. Here as part of the work of an international consortium,

the 3.2A structure of the 70S ribosome from the Enterococcus faecalis strain OG1 is described. This is

the first enterococcal ribosome structure reported to date and the quality of the structure is suitable for

antibiotic binding studies and inspection. The structure contains nearly complete 23S, 16S and 5S RNA

structures and excellent protein completeness. One uncharged t-RNA was found in the E site and

notable distinct ribosomal conformers were identified in some of the substructures studied. Significant

variation was also noted in the enterococcal ribosome relative to standard reference structures

suggesting that this ribosome structure should be a valuable resource for drug discovery work in the future.

Timing of surgical antibiotic prophylaxis: Is there a “sweet spot” in the hour before knife to skin?

Arthur J Morris,1,2 Sally A Roberts,1 Tanya M Jackways.2

1 Health Quality and Safety Commission Surgical Site Infection Improvement Programme (SSIIP), Wellington.2 Southern Cross Hospitals Network, Auckland, New Zealand.

Introduction: On time surgical antibiotic prophylaxis (SAP), ie. administration in the hour before knife to

skin (KTS), is associated with fewer surgical site infections (SSIs) than SAP given early (>60 minutes before

KTS) or late (after KTS). It is unclear, however, if there is an optimal time, a “sweet spot”, within the hour before KTS that is associated with the lowest possible SSI rate.

Methods: Data from two large prospective SSI surveillance and quality improvement programmes were

combined for procedures where the SAP timing, in minutes, had been recorded. There were 23,999 hip

and knee procedures in the SSIIP and 47,617 procedures in Southern Cross Hospitals (SCH) data set. Both

programmes used CDC/NHSN SSI definitions. Patients were followed for 90 days in the SSIIIP and 30 days

in SCH.

Results: On time prophylaxis reduced the SSI rate by ~40%, 1.7% vs. 2.9%, OR 0.58 (95% CI 0.49-0.68),

p<0.0001. When SAP was delivered 6-60 minutes before KTS the SSI rate was ~30% lower than when SAP

was given 1-5 minutes before KTS, 1.6% vs. 2.3%, OR 0.67 (95% CI 0.59-0.78), p<0.0001. When SAP was

delivered 16-30 minutes before KTS the SSI rate was ~25% lower compared to all other on time doses,

1.4% vs. 1.9%, OR 0.73 (95% CI 0.65-0.84), p<0.0001, and ~20% lower than all other on time doses excluding 1-5 minutes before, 1.4% vs 1.7%, OR 0.81 (95% CI 0.70-0.93), p<0.003, Figure.

Figure. SSI rate (%) vs. timing of surgical antimicrobial prophylaxis, minutes before KTS.

Conclusions: On time prophylaxis reduces the SSI rate. SAP given 1-5 minutes before KTS is less effective

than when given earlier. There may be a sweet spot 16-30 minutes before KTS that results in the lowest

SSI rate. Efforts should be made to ensure SAP is timed to provide the optimal protection against SSIs.

Disclosure of interest statement: No disclosures. This report is self-funded.

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Early 46-60mins 31-45mins 16-30mins 11-15mins 6-10mins 1-5mins Late

The molecular epidemiology of a MIRU-VNTR linked Mycobacterium tuberculosis cluster in New Zealand

Playle V.M1, Basu I1, Cook G.M2,3, Aung H.L2,3, Crawshaw S4, Hay D4, Roberts S1,3

1. LabPlus, Auckland District Health Board, New Zealand

2. Department of Microbiology and Immunology, School of Biomedical Sciences, University of Otago, Dunedin, New Zealand

3. Maurice Wilkins Centre for Molecular Biodiscovery, University of Auckland, Auckland, New Zealand

4. Auckland Regional Public Health Service

Funding Bodies: Auckland District Health Board Charitable Trust (A+ Trust)

Introduction: In New Zealand universal molecular typing of culture positive TB cases using MIRU-VNTR

has occurred routinely since 2003. It is used to augment epidemiological investigations for contact

tracing of tuberculosis cases (TB). MIRU-VNTR interrogates only a fraction of the genome (<1% of the

genome). As a consequence transmission can be excluded with greater certainty than it can be ruled in.

Additional epidemiological data is required when MIRU-VNTR genotypes match in order to determine

the likelihood of cases being linked. Studies have shown that within MIRU-VNTR-defined cluster whole

genome sequencing (WGS) offers sufficient resolution to identify or discount outbreaks as isolates

sharing the same MIRU-VNTR fingerprint may in fact have significant genomic diversity outside these regions.

Aim: To describe the molecular epidemiology of a MIRU-VNTR linked cluster of TB cases in New Zealand using WGS.

Method: All TB cases belonging to NZ cluster 45-001 or 45-002 with identical/near identical MIRU-VNTR

profiles were identified and subjected to WGS. Epidemiological information obtained from Public Health Services was used to determine if there was an established epidemiological link.

Conclusions: WGS provided greater discriminatory power than MIRU-VNTR typing. The results of this

research will be presented. This information has the potential to guide public health investigation of MIRU-VNTR linked clusters in New Zealand.

Sepsis Assessment at the Point of Care

Nigel Raymond

This presentation will discuss sepsis assessment at the point of care, with an aim of developing tools to

improve assessment and management. Improving management of sepsis has been an international

focus, such as with the Surviving Sepsis Campaign. In 2016 new Sepsis-3 definitions were proposed,

emphasizing both a dysregulated immune response and sequential organ failure, along with the SOFA

and quick SOFA (qSOFA) scores. In the UK, the national early warning score (NEWS) and Sepsis Six

bundle have been promoted. The Scottish NHS have provided a phone app as a tool to facilitate this, and

we are considering the specifications for developing a local app. To be used in practice, any sepsis tool

would need to address the clinical concerns of junior doctors and other staff and be suf ficiently user

friendly. Each of the sepsis scores vary in their performance and their use depends on the treatment or

management being considered. Besides acute treatments such as antibiotics & IV fluids, other potential

benefits of more accurate sepsis assessment may include antibiotic stewardship, communication with

patient & family, patient disposition, surveillance and research. Patient age, chronic health trajectory,

frailty and goals also commonly have a bearing on the management and prognosis of those with sepsis.

Diagnostic stewardship: putting up barriers or improving provision of care?

Title block: An audit of a recently implemented policy of requiring clinical details in the microbiology laboratory.

Authors:

Arlo Upton 1, Gayleen Parslow 1, Bosco Yip 2, James Ussher 1,2.

1 Microbiology, Southern Community Laboratories

2 University of Otago

Background

The provision of healthcare is constrained by scarcity and rationing is inevitable, as demonstrated by

waiting lists, over-flowing emergency departments, house surgeons queuing outside the on-call

radiologist office, etc. One area that has been relatively spared to date is laboratory medicine, where

for the most part referrers get the tests they ask for. However, we believe this has led to inappropriate

microbiology tests that may lead to inappropriate antibiotic prescription.

Methods

After a consultation process and grace period, on 30 July 2018 a policy of requiring appropriate clinical

details for (most) microbiology test processing at SCL Dunedin and Invercargill was enforced. Test data

for a month prior and after the implementation were extracted from the laboratory information system to audit the process, as a quality initiative.

Results

The total extract included 27674 test panels from 20100 patients: 66% female with a median age of 38

years (range: 0 – 103). Comparison of the pre- and post-intervention panels demonstrated a drop in the

number of urine and genital tests performed. In the post-intervention period studied half of the initially

declined tests where subsequently tested after communication from the referrer. Urines featured

prominently.

Conclusions

Our audit demonstrates that a diagnostic stewardship protocol is possible with good communication and a focus on healthcare quality.