“We have a lady with puerperal fever. She’s 2 days post-delivery and pretty unwell. Critical Care are reviewing her now and we’d like some advice about the best antibiotics to give her” said the Obstetrics Registrar.
 
Excellent thought the Microbiologist; they’re being proactive about a serious problem.
 
“If she’s not allergic to anything then IV Benzylpeniciilin and Clindamycin. Have you looked for retained products and done a DNC?” asked the Microbiologist.
 
“She’s really unwell, we don’t really want to take her to theatre. We might damage the uterus” replied the Registrar.
 
“She’s unlikely to improve if you don’t,” said the Microbiologist sympathetically. “You need to remove as much infected material as you can. I know it sounds brutal but it’s really important”.
 
“Okay,” said the Registrar sounding doubtful, “my Consultant is with the patient at the moment so I’ll go and tell them what you have advised. Thanks for your help.”
 
The Microbiologist put down the phone and put down his pen. Time to visit the obstetric ward and see what is going on…
 
What is the cause of puerperal fever?
Puerperal fever is caused by the bacterium Streptococcus pyogenes, also known as the Group A beta-haemolytic streptococcus. The bacterium can be either introduced from the mothers own flora, the attending healthcare professional or even from a contaminated environment. The bacterium then causes inflammation in the genital tract and ascends into the uterus causing what is known as endometritis (inflammation of the uterus).
 
The history of puerperal fever
Puerperal fever has an important historical context in the world of infection control and microbiology. Back in the 1700s and 1800s puerperal fever was a leading cause of maternal death. Puerperal fever was particularly common in “lying-in wards” (a room where women were confined in childbirth), especially those which were staffed by “accoucheurs” as the Doctors practicing in the “new field of obstetrics” were known; “accoucher” in French means ‎“to give birth”, or to “go into labour”.

In context, this “realisation” is all-the-more remarkable as the cause of puerperal fever was still unknown and many “experts” believed puerperal fever was caused by toxic miasmas (bad air), imbalance of the four humours or even excessive build-up of faeces in the mother’s bowel!
 
But it’s what Semmelweis did next that really makes him stand out. He put in place procedures to ensure that all doctors entering the wards washed their hands in a dilute chlorine solution and the effect was dramatic. When he compared the clinic where hand washing was in practice with a clinic where it wasn’t he saw the mortality had dropped from 12% to 3%!

​So Semmelweis was hailed as a hero and his handwashing practice immediately adopted all across the World…?! Not exactly, in fact no he wasn’t and neither was handwashing. His ideas went against the current opinion and dogma of the medical profession. Not only that, but many Doctors took offence at the suggestion that “their hands were dirty” and “that they were the cause of the disease” (reminds me a bit of trying to implement hand-hygiene even today!). Semmelweis was in fact ridiculed and rejected, he was sacked by the Vienna Hospital (partly because of political unrest relating to Hungary) and he had to move to Budapest.
 
Unfortunately Semmelweis’ story does not have a happy ending. He continued to try and convince people of his ideas with no success. In 1865 he suffered a breakdown and his “colleagues” had him forcefully committed to a “mental institution”. It is thought that he was beaten by guards, put in a strait jacket and locked in a darkened cell. He died 2 weeks later due to sepsis from an injury he sustained, during the scuffle, to his right hand... ironically it was probably the very bacterium he had spent his career trying to control, Streptococcus pyogenes!
 
Nowadays we refer to Semmelweis as the “Father of Infection Control” because he was the first person to show that close attention to hand hygiene reduces rates of infection. An amazing piece of work and Semmelweis is now rightly recognised for what he did, even if at the time he was treated so badly.
 
How does puerperal fever present?
Puerperal fever presents with fever during labour or up to 10 days after delivery. It is associated with severe abdominal pain and offensive bloody vaginal discharge. Often patients appear a lot sicker than the clinical findings in the genital tract, with tachycardia, hypotension and sepsis.
 
Any swabs taken from the vagina or placenta, as well as blood cultures, usually grow S. pyogenes, although endometritis itself can be caused by numerous other bacteria. It is the severity of the presentation that is the usual clue to this being S. pyogenes.
 
How should puerperal fever be managed?
Puerperal fever due to S. pyogenes is an obstetric emergency. Treatment consists of source control, antibiotics and supportive care with fluids and antipyretics etc.
 
Source control is the most important aspect of the management of puerperal fever. Patients often have retained products of conception (RPOC); these are bits of placenta still within the uterus. The location and nature of RPOC makes the infection difficult to treat and antibiotics less effective so these RPOC need to be removed, usually in a procedure with the unpleasant name of a dilatation and curettage (DNC). This should be done as soon as possible and can be life-saving.
 
Infection with S. pyogenes is often severe and requires the antibiotics IV Benzylpenicillin and IV Clindamycin to treat it. I tend to use both together because Benzylpenicillin kills the bacterium and Clindamycin interferes with the bacterium’s ability to produce toxins which makes the combination particularly effective.
 
Puerperal fever due to S. pyogenes is also an urgently notifiable disease. Public Health England will trace all household members and consider giving antibiotic prophylaxis, or eradication therapy, in order to prevent any further cases of infection caused by this aggressive bacterium, e.g. cellulitis, tonsillitis, septic arthritis and even necrotising fasciitis.
 
By the time the Microbiologist got to the obstetric ward (in our modern hospital scenario not the 1840’s “lying–in” ward!) the Consultant Obstetrician had already advised the operating theatre team of the need to do an emergency procedure.
 
With excellent source control, antibiotics and Critical Care support the patient made a full and speedy recovery and was soon back home with her new baby; a relief to all concerned. Fortunately there were no further cases on the obstetric ward but even so everyone continued to pay close attention to washing their hands…
 
If you’re interested in knowing more about the history of puerperal fever and Semmelweis there’s a nice little, easy to read, book called “The Doctor’s Plague” by Sherwin B. Nuland which is very good.
 
…I’m off to catch up on Charité season 2!

Happy Valentine's Day! The Love Virus is in the air...
“Chinese media are showing hardworking hero stories, it's Jeong Jae Pung’s wedding anniversary … ‘come home soon’ his sign says [according to the BBC reporter] … his wife is a nurse looking after virus patients and contact with the outside world is forbidden…” (BBC News at 10, 13/02/2020)

So what’s wrong with this picture?
The nurse is on a mobile phone wearing her PPE outside of the hospital, according to the UK’s guidelines it should be removed inside the patient’s room and why is she using her mobile phone?!

This breaches Infection Control policy in so many ways; leading to contamination of the hospital and the wider environment and also exposes this person and their family to the virus. She might as well not bother wearing the PPE at all.

This picture is so crazy it deserves a caption competition, no prizes, just the kudos for being the wittiest reader of the bug blog!
​
Add your caption below or on Facebook :-)

It’s all over the news; a new deadly plague is spreading across the World in an unstoppable wave of death and disease! Cities are falling, governments are collapsing, mass panic and chaos are ensuing… or at least that’s what the media would have us believe about the novel coronavirus from Wuhan in China. Gosh, it’s reminding me of the game of Pandemic!

What is 2019-nCoV?
2019-nCoV (originally known as Wuhan Virus) is in the coronavirus family along with SARS Virus (Severe Acute Respiratory Syndrome) and MERSCoV (Middle-Eastern Respiratory Syndrome Coronavirus). Both of these viral infections caused a stir Worldwide due to a relatively high mortality in those affected, even though the incidence remained very uncommon. SARS was particularly nasty once it got established in crowded hospitals as many of those affected were actually the healthcare workers looking after the patients. The cynic in me also thinks they caused a stir because they had catchy acronyms which allowed the media to present popular horror stories to frighten the public into watching more news stories…!
 
There is emerging evidence from researchers analysing the genetic sequence that suggests 2019-nCoV is a “recombinant virus between the bat coronavirus and an origin‐unknown coronavirus … [with a] snake the most probable wildlife animal reservoir”. As is the case with most new coronaviruses there is an animal source; SARS was from horse-shoe bats, MERSCoV from camels (“Camel Flu”, as I like to call it), and countless other new infections in animals such as swine acute diarrhoea syndrome, mouse hepatitis virus and even ferret systemic coronavirus! I particularly like the idea of Ferret Fever…
 
What is the current situation?
As of the 5th February the World Health Organisation have reported 24,554 confirmed cases of 2019-nCoV; 24,363 in China (16,678 from Hubei Province where Wuhan City is located) and 191 from the rest of the World; almost all cases outside of China had a travel history to China. So far only 2 cases have been detected in the UK out of 414 tested.
 
There have been 492 deaths (all in China, except 1), and those that have died had severe co-morbidities that would predispose them to a high mortality from any viral respiratory infection. The mortality is therefore currently around 2% but remember, in the initial stages of an outbreak the epidemiology is skewed towards severe cases as widespread surveillance for mild or asymptomatic cases has not yet been done; the overall mortality will be lower than this.
 
Okay, so on the face of it, this does sound bad but let’s just take a breath and try and bring some context to this. Hubei Province has a population of about 60 million, almost as big as the UK (65 million); which means the incidence of 2019-nCoV infection in Hubei is about 1 in 3,500, and in China with a population of about 1.4 billion the incidence is 1 in 60,000.
 
Let’s compare this to something more familiar, “common” influenza. In the USA this influenza season (2019/2020) there have been 19 million cases of flu, 180,000 admissions to hospital and 10,000 deaths. If we extrapolate these figures to China then there have been about 760,000 cases of influenza with 40,000 deaths so far this year which significantly dwarfs the situation with 2019-nCov.  Even in the UK there are 2-3,000 deaths a year from influenza. Influenza is still a much higher risk to public health in the UK than 2019-nCoV.
 
What has China done about 2019-nCoV ?
In my opinion the response from the Chinese authorities has been amazing. They have been quick to implement strict quarantine measures and quick to share information with the WHO and the global community. This has meant that diagnostic tests have been rapidly developed and vaccines are already being worked on. I doubt any other country in the World could have achieved this. They have even built a 1000 bed hospital in 10 days; in contrast in September 2019 the Health and Social Care Secretary Matt Hancock announced the UK will spend £2.8 billion on 6 new hospitals to be built in 5 years!
 
The Chinese authorities were also quick to close Huanan Seafood Wholesale Market in Wuhan City where poultry, snake, bats, and other farm animals were being sold. But as of the 1st January this year it was increasingly clear that the outbreak was no longer due to the exposure at the seafood market; there was evidence that 2019-nCoV could also spread from human-to-human.
 
How does 2019-nCoV infection present?
Like most coronaviruses, 2019-nCoV infection presents with a flu-like illness; fever, cough, sore throat, shortness of breath. The key aspect is the travel history i.e. has the patient potentially been exposed to 2019-nCoV … if not then it’s not the 2019-nCoV.
 
The current case definition for infection is:
 
Severe acute respiratory infection requiring admission to hospital, with clinical or radiological evidence of pneumonia, or acute respiratory distress syndrome
OR
Acute respiratory infection of any degree of severity (including at least one of: shortness of breath, cough or sore throat)
AND
In the 14 days before the onset of illness:

• Travel to mainland China OR
• Contact with confirmed cases of 2019-nCoV, defined as:

1. Living in the same household, OR
2. ​Direct contact with the case or their body fluids or their laboratory specimens, or in the same room of a healthcare setting when an aerosol generating procedure is undertaken on the case OR
3. ​Within 2 metres of the case in any other setting not listed above, for any length of time
   

If anyone fits this case definition then they should be discussed immediately with the local Duty Microbiologist or Infectious Diseases Physician, who will liaise with the local Public Health England Health Protection Team.
 
How is 2019-nCoV diagnosed?
The current sample types required from patients in the UK with possible 2019-nCoV are:

• Viral nose and throat swab OR nasopharyngeal aspirate (NPA) for PCR
• Sputum OR bronchoalveolar lavage (BAL) for PCR
• 5ml Clotted blood (1ml for children <12 years old) for antibody testing (acute and convalescent 14 days later)

 
Testing should be discussed with the local Public Health England Health Protection Team before sending samples to the Reference Laboratory; this should be done by the Duty Microbiologist or Infectious Diseases Physician.
 
REMEMBER to take samples for all “normal” respiratory infections as well as those required for 2019-nCoV, your patient is far more likely to be ill from a “usual” condition. Note: local laboratory testing for Influenza Virus as well as other causes of pneumonia should be undertaken in a Category 3 facility, which is normal protocol.
 
Dealing with the media and public concerns
I returned from holiday to find a free newspaper on the train saying “deadly virus” and was travelling next to two young men wearing surgical masks! No one even mentioned the virus in Fuerteventura!
 
So what about the concern for bringing “our” citizens home from China? I’m not convinced this was entirely driven by health advice. Putting asymptomatic people on an aeroplane with others is OK as the virus (as with all respiratory viruses) is transmissible through droplets; no droplets on hands or in the air (sneezing and coughing) means no virus risk. However it does place all these people in close proximity with others who have a high risk factor for exposure, so if someone on board the aeroplane becomes symptomatic all on board are then at risk of further exposure. I suspect this evacuation was more political and media led. As for the “all must leave” message, well the WHO currently advise against the application of any travel or trade restrictions on China.
 
The other story that caught my eye regarded the transferring of asymptomatic people in a coach from the evacuation aeroplane to their quarantine facility. A member of the transporting team could clearly be seen in full PPE next to the “unprotected” coach driver. The PPE was unnecessary; remember it’s the symptomatic patients who spread the virus. It was poor practice to be in PPE as all PPE should be removed after assessment of a patient, be it within the patient’s room or anteroom. If the PPE is contaminated wearing it on a coach around the country or around the hospital clearly puts more people at risk and is against advice.
 
In contrast the PHE infection control advice that “all transfer staff should wear full PPE and maintain a 2 metre PPE protection zone around the patient and their equipment” (see PPE below) is recommended for confirmed symptomatic patients and enables the staff member to be able to respond to the patient’s needs if required, can you imagine trying to explain that “the patient was chocking but we delayed our treatment as we had to put on our PPE!”?
 
So will a surgical face mask help me on the underground? No, normal surgical face masks do not filter air and will not stop someone inhaling anything! Why wear them in surgery then?!? A surgical mask stops contamination from skin and sweat from the surgeon “dropping” onto the surgical site and should prevent the surgeon touching their nose and mouth during the procedure! Why are patients asked to wear these face masks during transport across a hospital (see PPE below)? The patient should wear a ‘surgical mask’ if this can be tolerated to prevent large respiratory droplets being expelled into the environment by the wearer, essentially it’s the same as the “coughing into a tissue” advice given to the public with Influenza Virus.
 
Of course people get concerned, it’s only natural, but playing into these fears (especially fuelled by the media) is not helpful.
 
How is 2019-nCoV treated?
There is no specific treatment for 2019-nCoV. Patients require good supportive care with fluids and ventilator support.
 
Infection Control Precautions
It is important to keep in mind that all of the current strategies for dealing with 2019-nCoV, including the current infection control precautions, are to try and prevent it becoming established in the population like influenza.
 
Human-to-human transmission of 2019-nCoV can occur, and has been demonstrated in this outbreak. By far the most important method of spread is respiratory droplets so hand hygiene is critical. This was the same for SARS and MERSCoV where the main factor related to the spread of infection in hospitals was how close did you get to the patient, i.e. were you in an area where respiratory droplets would land (within 2 metres) and therefore be contaminated by the patient?
 
All travellers from Hubei Province are expected to self-isolate themselves within their own homes for 14 days whether they have symptoms or not; travellers from other areas of mainland China should isolate themselves if symptomatic. If they develop any of the symptoms of 2019-nCoV infection they should ring NHS 111 for advice rather than attend their GP practice or local hospital. NHS 111 will arrange for the patient to be assessed in the appropriate setting. A symptomatic patient attending a healthcare setting unannounced will put other people at risk of infection.
 
Infection control within the home - all exposed and symptomatic patients should “catch it, bin it, kill it” using tissues when coughing or sneezing. The virus is likely to only survive about 15 minutes on a tissue, like other respiratory viruses. Then the person should wash their hands with soap and water.
 
A summary of the infection control requirements in hospital is in the table, for more details see the current guidance from the Department of Health.

It is slightly trickier in primary care. Patients should be asked about travel history via phone if possible or at reception as part of triage. If someone has a travel history that suggests a risk of infection then they should be asked to stay at home and wait for a telephone consultation, or if in the surgery directed to a room on their own, away from other patients. They should not use the usual waiting room. If however risk comes to light during the consultation then the doctor should withdraw from the room, close the door and wash their hands with soap and water. Evaluation of the patient should ideally continue via telephone from outside of the room. Once this has been done then discussion with the local microbiology or infectious diseases services should take place to decide if assessment and investigation is required. For more details see the current Department of Health guidance for Primary Care.
 
So rather than go back to bed and hide under the duvet I think I’m just going to stop watching the news and only read the bulletins from WHO or Public Health England to get my outbreak information from now on… although perhaps I should have stayed on holiday for a few weeks longer until all of this settled down… now there’s an idea!
 
In other news today, a Briton has claimed the Guinness World Record for the largest onion bhaji ever made; the media headline is likely to be something like “Panic as National mango chutney shortage after over production of a gargantuan Indian side dish!”

The Microbiologists were out having their Christmas curry together when the oncall phone twitched into action. Looking around the table, under pulled crackers and wrapping paper, the oncall Microbiologist (the only one not drinking!) took the call while the others ordered some more drinks and food… It was a noisy gathering as Microbiologists don’t get out much…
 
The waiter looked expectantly to take more drinks orders….
 
“I’m sure she said a mango lassie, I’ll get her one …yes… one mango lassie please and five cobra beers and another taka dahl, thanks”. The waiter scuttled off.
 
“I ordered you the mango lassie” said the (tipsy off duty) Microbiologist
 
“Why did you get me a lassie?” asked the oncall Microbiologist.
 
“You said mango lassie while on the phone… when we were ordering more drinks… didn’t you!?!”
 
“No… that was the Med Reg from the Royal Free, saying they thought one of contacts of the Dutch Lassa fever cases might be transferred to us for follow up and thought we’d like to be aware, as it was in the news and may cause us a call or two if the local media get to know!”… continuing… [and huffing]  “Really… its 10:30 on Friday night, I do not need to know this oncall, but everyone wants their minute of fluster and fame!!” … “Mango lassie…?! You lot need a hearing test or less Cobra beer!” said the oncall Microbiologist.
 
“5 Cobras and a mango lassie…” said the waiter with impeccable timing!
 
The Microbiologists crumpled in laughter and thanked the waiter who just looked puzzled and said he’d bring over the dahl.

Warning: this blog mite make you itch!
 
The Oncology Registrar sat in the Multidisciplinary Team meeting looking thoroughly miserable. They looked like they hadn’t slept for ages, and whilst this can often be the case for junior doctors, the Microbiologist knew the registrar had only just returned from annual leave.
 
Whilst trying to pay attention to the patient discussions the Microbiologist watched as the poor Registrar kept scratching at his hands and arms.
 
As the meeting drew to a close, the Microbiologist wandered over…they can’t help but meddle!!!
 
“You look like your suffering” he said sympathetically, when in fact he was “itching” to make a shrewd diagnosis!!!
 
“Yeah. My hands and arms are really itchy, and it was worse in that room as it was so hot. I think I’m allergic to something”.
 
The Microbiologist wasn’t so sure.
 
“Show me your hands” he said.
 
The Registrar helpfully held out his hands which looked red and inflamed.
 
Looking closely whilst not touching (oooh, all those germs!!! He’d seen the Infection Control hand plates in the past!!!) the Microbiologist soon realised the likely cause of the problem.

The Microbiologist was slowly meandering through the daily authorisation, trying to stay awake and not authorise something important without seeing it first… honestly we do really pay attention but it can be a little dull authorising out more than a hundred urine results a day!
 
Suddenly something caught their eye. A wound swab was growing Candida auris. The Microbiologist sat up straight in his chair (I am notorious for slouching at the duty desk!) and picked up the phone to find out more.

It was a hot and dozy afternoon in the microbiology lab. The air-conditioning system was on the blink again and a nice large lunch of sausages, chips and beans had made the Microbiologist particularly sleepy. The telephone rang.

​​“My patient has plague!” screamed the excited junior doctor.

​I’ve had the dubious pleasure of dealing with various incidents and outbreaks over the years. They can be very stressful experiences for everyone concerned, but a clear methodical approach can go a long way to alleviating the levels of stress both in both you and your colleagues.
 
Imagine the scenario:
It’s 9am and the Senior Biomedical Scientist knocks on your door “ummm the laboratory has inadvertently processed a tissue sample containing Brucella melitensis on the open bench!”

The patient was admitted 3 days after arriving in the UK from Nigeria. He had felt unwell with a fever and generalise aches and pains the day before he travelled. On the morning of admission he had noticed a rash on his left leg as well as tender enlarged lymph nodes in his groin.
 
The admitting Consultant Physician spoke to infection control before the patient arrived and it was decided to admit the patient directly to a negative pressure side-room in the infectious diseases unit without bringing the patient into the main hospital in case this might be a viral haemorrhagic fever. The patient met a diagnosis of low possibility of viral haemorrhagic fever; temperature ≥ 37.5 oC PLUS been in endemic area within 21 days of onset of illness.

Between 2000 and 2003 a large outbreak of Clostridium difficile occurred in Montreal, Quebec, Canada. There are differing reports as to the extent of the outbreak, but some estimate that in 8 hospitals there were 7,000 cases and 600 deaths in 2003. This is at least a 5 fold higher incidence and mortality than considered “normal” by the Canadian public health officials. The strain of bacterium was identified as the now notorious O27 strain, but it was soon realised that this “outbreak” was in fact going on all over the World, not just in Quebec. Apparently Clostridium difficile means the “obstinate spindle” bacterium… and I think all Microbiologists would agree with the term, though some of us might be less polite in our language!