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.

Looking down the blood cultures list whilst prioritising what needed phoning out first the Microbiologist noticed a blood culture positive on day 3 with a Gram-positive bacillus in the aerobic bottle only. Normally this wouldn’t provoke much interest as most pathogens grow within 12-24 hours and most Gram-positive bacilli are skin contaminants (Corynebacterium spp. and Cutibacterium spp.). However these were unlikely in this case: Corynebacterium spp. normally grow faster than this and would be in both bottles whereas Cutibacterium spp. although anaerobes tend to grow much slower. The clinical details just said “fever” (not overly helpful!) and considering the sample was 3 days old already, it didn’t seem that urgent, so the Microbiologist put it to the bottom of the list and got on busily calling out all of the Gram-negative bacilli and Gram-positive cocci, as these were more likely to be significant.

I am really fortunate to work with a great team of diagnostic cardiologists who have a keen interest in infective endocarditis. We have an endocarditis multidisciplinary team and do a ward round of all the endocarditis patients every week, regardless of where they reside in the hospital. One of the big problems for these patients is the long courses of IV antibiotics in the current treatment guidelines, be they British, American or European. As a result patients have long periods of time where they have central venous catheters (CVC) for administering the antibiotics and prolonged hospital stays; both predisposing to further infections.

​So when I saw an article in the New England Journal of Medicine from Denmark investigating whether oral antibiotics can be used in the treatment of this infection, my attention was stirred and I made the most of the present moment and ordered the paper from the library, “carpe diem”.

I have been to a number of meetings and had numerous discussions with colleagues, who lament the loss of the practical component of the Fellowship of the Royal College of Pathologists (FRCPath) exam. With a tear in their eye they talk about the “good old days”, that the exam was “character building” and how “trainees today have it so easy”… but is this really true? Was the practical exam such an essential element of the examination, were we made better for completing it; were those days really all rosy and wonderful as they say? And if so why has it been changed?
 
Back in the dim distant past when I took my FRCPath exam it was very different to what it is now. In 2003 the FRCPath consisted of two parts, and was sat after 1-3 years in a Registrar post. You needed to “lose some sense of reality” my wife says in order to submerge yourself enough to pass!

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.

The Practice Nurse was getting a bit bored, sitting in the travel clinic listening to all of these people wanting advice for their various holiday destinations. There was only so much advice she could give for beach holidays to Ibiza and Magaluf. So when she opened the next patient record and saw it was a couple about to go on a wildlife spotting trip to Madagascar, she said out loud… “ooh that’s a bit more like it!” and called them in…

​One of the most common bacterial infections we see in the hospital setting is cellulitis; an infection of the skin and subcutaneous tissues. Most of these are caused by Gram-positive bacteria such as Staphylococcus aureus and the Beta-haemolytic streptococci. First line antibiotic treatment is usually Flucloxacillin, or Teicoplanin or Vancomycin (if the patient is allergic to beta-lactams such as Flucloxacillin). I have recently got to thinking about new antibiotics that might be useful in the treatment of cellulitis and in particular a new cephalosporin called Ceftaroline, which is supposedly active against all S. aureus including MRSA and the Beta-haemolytic streptococci.
 
So what have I found out about Ceftaroline? How does it work? Why is it active against MRSA? Read on to discover the answers to these questions and many more about this new antibiotic…