Hospital acquired infections are never a good thing, usually there is simply lapse in care, resources or common sense behind most occurrence. The normal kinds of infection you “expect” to see being acquired in hospitals are MRSA, Norovirus or Clostridium difficile. However sometimes outbreaks can be a real mystery to solve. I have had to deal with an unusual outbreak of hospital acquired fungal infection myself, so I was intrigued to “read on” when I saw this week’s headlines that “a strange outbreak had occurred in a Scottish hospital”.
 
This outbreak occurred at the Queen Elizabeth University Hospital in Glasgow and sadly patients have died as a result. An outbreak is defined when there are two or more cases linked in time, place or person. A single infection can constitute an outbreak if the infection is significantly rare or unlikely in the particular situation. The Glasgow outbreak is unusual in that it is not the normal kind of infection you expect to see being acquired in hospitals, this was cryptococcosis.
 
Cryptococcosis is a fungal infection caused by yeast like organisms of the family Cryptococcus spp. There are three main subspecies which infect humans:

• Cryptococcus neoformans var. neoformans
• Cryptococcus neoformans var. grubii
• Cryptococcus gatii

 
Cryptococcus spp. are found worldwide and throughout the environment; C. gatii is mainly found in the tropics whereas C. neoformans is more common and widespread. C. neoformans is principally found in pigeon droppings and pigeon nests as well as soil whereas C. gatii tends to be found in the bark of trees as well as soil. Other animals have been known to carry Cryptococcus spp. including cats, dogs, horses and even camels, llamas and alpacas!

Okay, so the Bug Blog is usually about the clinical and scientific aspects of microbiology but this week I’m going to do something a bit different. Now I’m not someone who watches much TV; there was very little on that interested me over the Christmas period. However, I did watch a short TV hospital dramatization called Charité on Netflix which I thought was brilliant and something that anyone interested in microbiology would also enjoy. OK so it’s in German with English subtitles, but it is the best show I have watched in a long time! Let me explain.

As some of you will be aware from reading previous New Year blogs (see Pandemic Legacy blog) I love board games and of course microbiology. This year Santa has brought me another brilliant bug board game combo… Plague Inc.
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This is the opposite to the Pandemic games in which humans battle to eradicate bugs; here you are the bug and the aim is to infect cities of the world and kill off entire countries and continents! Now I feel this game lacks the shear panic that Pandemic Legacy gave me but it has meant I have slept over the two weeks of Christmas, which I did not when playing Pandemic Legacy (the ultimate, epic, scary and brilliant game for Microbiologists and all those interested in infection).

But back to Plague Inc, you start as a bacterium (all bacilli of various colours) with one country that you already infect and 5 Trait Cards. You gain DNA points (1 bonus point each round plus 1 for each country where your infection cubes are in control) that allow you to evolve by buying a trait from the Trait Cards you hold in your hand… At the start your bacterium has little potency (2 DNA points) so the game feels a bit slow, but it will grow on you!

​The Microbiologist was sat at his desk Boxing Day morning authorising out results and waiting for some further work on the blood cultures before ringing them out when his oncall mobile phone went off.
 
“Hi, it’s the ED Registrar here; can I discuss a patient with you?”
 
“Of course, what have you got” answered the Microbiologist.
 
“We’ve got a chap who has recently been abroad and has presented with a fever and feeling unwell. The basic story is that he returned home from work in the early hours of this morning looking flushed and tired. His wife was worried about him, as his belly was rather distended, so persuaded him to come to the hospital. He insists this is how he normally feels at this time of year but his wife isn’t convinced.”

Sometimes you come across a patient who represents the perfect storm of allergies, resistance and contra-indications to antimicrobials that really make you scratch your head to come up with a way of treating them. I’m not complaining! These are the kind of clinical conundrums that stretch the brain cells and make Microbiologists earn their money

I was recently doing a ward round on the Critical Care Unit when a Doctor from overseas who was observing on the ward starting asking questions about how we give antibiotics in the UK and why we don’t use continuous infusions. This was a really good discussion, especially as we have recently been thinking about if we should be implementing this method of antibiotic administration locally.

The patient was a young man in his early 20s. He presented to the Emergency Department with pain in his neck and difficulty swallowing. He managed to tell the ED Doctor that he had had a bad toothache for over a week but had been putting off seeing a Dentist because “he had too many other things to do”.
 
On examination he was febrile and tachycardic and his respiratory rate was high. The ED Doctor could see that his neck was swollen even by looking from the end of the bed.

“I have a 3 year old patient with an infected ulcer on their leg which is proving particularly difficult to treat” was the opening statement from the Surgeon.
 
“What antibiotic are you giving?” asked the Microbiologist in a surly tone, thinking this was going to be a simple case of wrong antibiotic.
 
“I’ve been using Co-amoxiclav, but it doesn’t seem to be getting better” was the reply.
 
“Have you sent any samples to the lab?”
 
“I swabbed the wound and the result has come back showing a Coagulase-positive Staphylococcus; I wonder if this might be Staphylococcus pseudintermedius or possibly Staphylococcus aureus” said the Surgeon.
 
“Staphylococcus aureus is the most common bacterium we see in this situation” answered the Microbiologist, “why do you think it might be Staphylococcus pseudintermedius?”
 
“In our patients Staphylococcus pseudintermedius is often grown from these types of samples…oh, I forgot to mention, I’m a Veterinary Surgeon and the 3 year old patient is a Husky” was the reply…. “I should say too that the bacterium is resistant to beta-lactams… according to the report…

The phone started to vibrate at midnight and the Microbiologist groaned. Who would be ringing at the witching hour on Halloween? Then he started to worry… would it be safe to answer? Would there be some crazy person on the other end? Was it a vicious axe murderer? Then he remembered this was just the scary film he had watched before going to bed and he was actually on call for the hospital.
 
The person on the other end turned out to be the Emergency Department Registrar (certainly crazy for working Halloween in the ED…!)
 
“I’ve got a patient who has been bitten on their hand by a bat and I wondered what antibiotics we should start. We have guidelines for dog, cat and even human bites but nothing for bats.”

When I was a Registrar I was lucky enough to do an MSc in Clinical Microbiology at Queen Mary’s University of London. This involved a really early morning once a week to catch a train from Nottingham to London, a two hour journey, a day of practical work and lectures, and then a two hour journey home (it was a gruelling day, gosh I was so lucky!). I learnt a lot doing the MSc and met some great people, but it was during these long train journeys that I came up with an idea about how to pass essay and short note exams. This method became known as the Seven Pillars of Waffledom, but more on why later.
 
How do you help your examiner mark your essays and short notes?
Now this isn’t about cheating! It’s just a polite observation. During the MSc we had to write essays and short notes on various topics, it was good practice as this was also the standard format of the three hour exam papers in the “olde” FRCPath Part 1 exam; I  quickly realised I had to get better at writing essays and short notes. I spoke to my Consultant Supervisors who used to mark these exam papers and they all said the same thing, “make sure your answers are clear and easy to read”. “Is that it?” I replied grouchily. Simply put yes it is, because if you write clearly and legibly your examiner is more likely to look favourably on your essay and may give you the benefit of the doubt with some of your answers. If your answer is illegible and disorganised or if it takes too long to decipher your answer, then they will not be so kind and you won’t get the mark. How long do you think it takes to read an essay and how long extra should they allow to read a badly written one?! This may seem unfair but it is human nature… it’s also a good lesson for clinical work, good communication is really important and that includes your written communication.