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    Determining the contribution of Streptococcus pneumoniae to community-acquired pneumonia in Australia

    J Kevin Yin, Sanjay H Jayasinghe, Patrick G Charles, Catherine King, Clayton K Chiu, Robert I Menzies and Peter B McIntyre
    Med J Aust 2017; 207 (9): . || doi: 10.5694/mja16.01102
    Published online: 6 November 2017

    Abstract

    Objective: To evaluate trends in the proportion and severity of community-acquired pneumonia (CAP) attributable to Streptococcus pneumoniae (pneumococcus) in Australians aged 18 years and over.

    Study design: Systematic review with unpublished data from the largest study.

    Data sources: Multiple key bibliographic databases to June 2016.

    Study selection: Australian studies on the aetiology of CAP in adults.

    Data synthesis: In the 12 studies identified, pneumococcus was the most common cause of CAP. Four studies were assessed as being of good quality. Participants in two studies were predominantly non-Indigenous (n = 991); the proportion of pneumococcal CAP cases declined from 26.4% in 1987–88 to 13.9% in 2004–06, and the proportion with bacteraemia decreased from 7.8% to 3.8%. In two studies with predominantly Indigenous participants (n = 252), the proportion with pneumococcal bacteraemia declined from 6.8% in 1999–2000 to 4.2% in 2006–07. In the largest study (n = 885; 2004–06), 50.8% (60/118) of pneumococcal CAP occurred in people who were ≥ 65 years old. Among patients aged ≥ 65 years, intensive care unit admission and death were more common in patients who were ≥ 85 years old compared with younger patients (12.5% v 6.8%; 18.8% v 6.8% respectively), and also more common in the 19 patients with bacteraemia than in those without it (15.8% v 2.6%; 10.5% v 7.9% respectively). Of 17 cases of bacteraemia serotyped, 12 were due to 13-valent pneumococcal conjugate vaccine (13vPCV) serotypes and three to additional serotypes in 23-valent pneumococcal polysaccharide vaccine (23vPPV).

    Conclusions: Available data suggest that the proportion of CAP attributable to pneumococcus (both bacteraemic and non-bacteraemic) has been declining in Australian adults. Should 13vPCV replace the 23vPPV currently funded by the National Immunisation Program for persons aged ≥ 65 years, surveillance to track non-bacteraemic pneumococcal CAP will be essential to evaluate the impact.

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      Rates of hospitalisation for herpes zoster may warrant vaccinating Indigenous Australians under 70

      Meru Sheel, Frank H Beard, Aditi Dey, Kristine Macartney and Peter B McIntyre
      Med J Aust 2017; 207 (9): . || doi: 10.5694/mja16.01468
      Published online: 6 November 2017

      Herpes zoster (HZ) is caused by reactivation of latent varicella zoster virus infection. The most common complication of HZ is post-herpetic neuralgia (PHN), which is often debilitating and refractory to treatment.1 The incidence of both HZ and PHN increases markedly with age.2 In November 2016, a vaccine for HZ was included in Australia’s National Immunisation Program (NIP) for all people aged 70, together with a 5-year catch-up program for those aged 71–79 years.3 The vaccine is cost-effective for people aged 70–79, but is registered for vaccinating people from age 50.3

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      • 1 National Centre for Immunisation Research and Surveillance, the Children's Hospital at Westmead, Sydney, NSW
      • 2 National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT
      • 3 University of Sydney, Sydney, NSW


      Acknowledgements: 

      This work was supported by the National Centre for Immunisation Research and Surveillance. Meru Sheel is a scholar in the Master of Philosophy in Applied Epidemiology program at the Australian National University.

      Competing interests:

      No relevant disclosures.

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        Epidemiology of invasive meningococcal B disease in Australia, 1999–2015: priority populations for vaccination

        Brett N Archer, Clayton K Chiu, Sanjay H Jayasinghe, Peter C Richmond, Jodie McVernon, Monica M Lahra, Ross M Andrews and Peter B McIntyre, on behalf of the Australian Technical Advisory Group on Immunisation (ATAGI) Meningococcal Working Party
        Med J Aust 2017; 207 (9): . || doi: 10.5694/mja16.01340
        Published online: 6 November 2017

        Abstract

        Objectives: To describe trends in the age-specific incidence of serogroup B invasive meningococcal disease (IMD) in Australia, 1999–2015.

        Design, setting, participants: Analysis in February 2017 of de-identified notification data from the Australian National Notifiable Diseases Surveillance System of all notifications of IMD in Australia with a recorded diagnosis date during 1999–2015.

        Major outcomes: IMD notification rates in Australia, 1999–2015, by age, serogroup, Indigenous status, and region.

        Results: The incidence of meningococcal serogroup B (MenB) disease declined progressively from 1.52 cases per 100 000 population in 2001 to 0.47 per 100 000 in 2015. During 2006–2015, MenB accounted for 81% of IMD cases with a known serogroup; its highest incidence was among infants under 12 months of age (11.1 [95% CI, 9.81–12.2] per 100 000), children aged 1–4 years (2.82 [95% CI, 2.52–3.15] per 100 000), and adolescents aged 15–19 years (2.40 [95% CI, 2.16–2.67] per 100 000). Among the 473 infants under 2 years of age with MenB, 43% were under 7 months and 69% under 12 months of age. The incidence of meningococcal serogroup C (MenC) disease prior to the introduction of the MenC vaccine in 2003 was much lower in infants than for MenB (2.60 cases per 100 000), the rate peaking in people aged 15–19 years (3.32 per 100 000); the overall case fatality rate was also higher (MenC, 8%; MenB, 4%). The incidence of MenB disease was significantly higher among Indigenous than non-Indigenous Australians during 2006–2015 (incidence rate ratio [IRR], 3.8; 95% CI, 3.3–4.5).

        Conclusions: Based on disease incidence at its current low endemic levels, priority at risk age/population groups for MenB vaccination include all children between 2 months and 5 years of age, Indigenous children under 10 years of age, and all adolescents aged 15–19 years. Given marked variation in meningococcal disease trends over time, close scrutiny of current epidemiologic data is essential.

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        • 1 National Centre for Immunisation Research and Surveillance (NCIRS), Sydney, NSW
        • 2 Sydney Medical School, University of Sydney, Sydney, NSW
        • 3 Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, WA
        • 4 University of Western Australia, Perth, WA
        • 5 Princess Margaret Hospital for Children, Perth, WA
        • 6 Victorian Infectious Diseases Reference Laboratory, at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC
        • 7 Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC
        • 8 Murdoch Children's Research Institute, Melbourne, VIC
        • 9 Neisseria Reference Laboratory and WHO Collaborating Centre for Sexually Transmitted Diseases, Prince of Wales Hospital, Sydney, NSW
        • 10 South Eastern Area Laboratory Services, Prince of Wales Hospital, Sydney, NSW
        • 11 University of New South Wales, Sydney, NSW
        • 12 Menzies School of Health Research, Charles Darwin University, Darwin, NT


        Acknowledgements: 

        The members of the Australian Technical Advisory Group on Immunisation (ATAGI) Meningococcal Working Party (2013) and of ATAGI (2013–2014) were Ross Andrews (chair), Michael Nissen, Peter McIntyre, Peter Richmond, Jodie McVernon, Sue Campbell-Lloyd, Karen Peterson, Monica Lahra, Ann Koehler and Julie Leask. We acknowledge the Office of Health Protection (Australian Government, Department of Health and Ageing) and the National Neisseria Network, Australia for providing the data; and all jurisdictional representatives on the National Surveillance Committee (NSC) and the Communicable Diseases Network of Australia (CDNA) for advice on interpreting jurisdiction-specific features of the notified data.

        Competing interests:

        The views expressed in this article are those of its authors, and do not represent the official position of or recommendations by ATAGI or the Australian Government.

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          The right to know versus the right to privacy: donor anonymity and the Assisted Reproductive Treatment Amendment Act 2016 (Vic)

          Xavier Symons
          Med J Aust 2017; 207 (9): . || doi: 10.5694/mja17.00259
          Published online: 6 November 2017

          Recent Victorian legislation is ethically defensible but will need to be closely monitored

          On 1 March 2017, the Assisted Reproductive Treatment Amendment Act 2016 (Vic) came into effect, allowing for the retrospective release of anonymous donor information to donor-conceived children.1 The legislation, an Australian first, allows donor children to know the name, date of birth, ethnicity, physical characteristics, genetic conditions and donor code of their donor parents, even where anonymity has been requested. Donor children can access information about their biological parents through a new “one-door-in” service to be provided by the Victorian Assisted Reproductive Treatment Authority (VARTA), which is now managing the state’s central donor registry and providing information and support to donor-conceived people, parents, donors and their relatives. The donors affected by the legislation are those who donated before 1 January 1998; anonymous donation ceased in Victoria after that date.


          • Institute for Ethics and Society, University of Notre Dame Australia, Sydney, NSW


          Correspondence: xavier.symons@nd.edu.au
          Competing interests:

          No relevant disclosures.

          • 1. Parliament of Victoria. Assisted Reproductive Treatment Amendment Act 2016 (No. 6 of 2016). http://www.legislation.vic.gov.au/Domino/Web_Notes/LDMS/PubStatbook.nsf/51dea49770555ea6ca256da4001b90cd/A1554C040E11C661CA257F69000A4A50/$FILE/16-006aa%20authorised.pdf (accessed Sept 2017).
          • 2. Victoria’s changes to laws on tracing sperm and egg donors a sensible evolution [editorial]. The Age (Melbourne) 2017; 2 Mar. http://www.theage.com.au/comment/the-ageeditorial/victoriaschanges-to-laws-on-tracing-sperm-and-egg-donors-a-sensible-evolution-20170302-guowdh.html (accessed Sept 2017).
          • 3. Pennings G. How to kill gamete donation: retrospective legislation and donor anonymity. Hum Reprod 2012; 27: 2881-2885.
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          • 6. Bruce N. On the importance of genetic knowledge. Child Soc 1990; 4: 183-196.
          • 7. Marko Harrigan M, Dieter S, Leinwohl J, Marrin L. “It’s just who I am … I have brown hair. I have a mysterious father”: an exploration of donor-conceived offspring’s identity construction. J Fam Commun 2015; 15: 75-93.
          • 8. Golombok S, Blake L, Casey P, et al. Children born through reproductive donation: a longitudinal study of psychological adjustment. J Child Psychol Psychiatry 2013; 54: 653-660.
          • 9. Mahlstedt P, LaBounty K, Kennedy W. The views of adult offspring of sperm donation: essential feedback for the development of ethical guidelines within the practice of assisted reproductive technology in the United States. Fertil Steril 2010; 93: 2236-2246.
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          • 11. Paul M, Berger R. Topic avoidance and family functioning in families conceived with donor insemination. Hum Reprod 2007; 22: 2566-2571.
          • 12. Scheib JE, Riordan M, Rubin S. Adolescents with open-identity sperm donors: reports from 12–17 year olds. Hum Reprod 2005; 20: 239-252.
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          • 15. Nordquist P. The drive for openness in donor conception: conception: disclosure and the trouble with real life. Int J Law Policy Family 2014; 28: 321-338.
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            Sinusitis complicated by frontal bone osteomyelitis in a young patient

            Roza Nastovska and Lyn-Li Lim
            Med J Aust 2017; 207 (9): . || doi: 10.5694/mja16.01434
            Published online: 6 November 2017

            A 15-year-old male presented with acute left forehead swelling (Figure, A, arrow) and tenderness following a one-month history of worsening headache secondary to extensive frontal sinusitis. Imaging showed a scalp abscess, frontal bone osteomyelitis and underlying resolving sinusitis (Figure, B, arrow). Management included abscess drainage and bilateral endoscopic sinus surgery. Streptococcus anginosus was isolated and he completed a 6-week course of intravenous benzylpenicillin.


            • Eastern Health, Melbourne, VIC


            Correspondence: roza.nastovska@gmail.com
            Acknowledgements: 

            We thank Jillian Lau for her contribution to the clinical case, editing of early drafts and contribution of clinical photography.

            Competing interests:

            No relevant disclosures.

            • 1. Bennett JE, Dolin R, Blaser MJ. Mandell, Douglas and Bennett’s principles and practice of infectious diseases. 8th ed. Elsevier: 2014.
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              The increasing importance of community-acquired methicillin-resistant Staphylococcus aureus infections

              Jason W Agostino, John K Ferguson, Keith Eastwood and Martyn D Kirk
              Med J Aust 2017; 207 (9): . || doi: 10.5694/mja17.00089
              Published online: 30 October 2017

              Abstract

              Objectives: To identify groups at risk of methicillin-resistant Staphylococcus aureus (MRSA) infection, patterns of antimicrobial resistance, and the proportion of patients with MRSA infections but no history of recent hospitalisation.

              Design, setting and participants: Case series of 39 231 patients with S. aureus isolates from specimens processed by the Hunter New England Local Health District (HNELHD) public pathology provider during 2008–2014.

              Main outcome measures: Proportion of MRSA infections among people with S. aureus isolates; antimicrobial susceptibility of MRSA isolates; origin of MRSA infections (community- or health care-associated); demographic factors associated with community-associated MRSA infections.

              Results: There were 71 736 S. aureus-positive specimens during the study period and MRSA was isolated from 19.3% of first positive specimens. Most patients (56.9%) from whom MRSA was isolated had not been admitted to a public hospital in the past year. Multiple regression identified that patients with community-associated MRSA were more likely to be younger (under 40), Indigenous Australians (odds ratio [OR], 2.6; 95% CI, 2.3–2.8), or a resident of an aged care facility (OR, 4.7; 95% CI, 3.8–5.8). The proportion of MRSA isolates that included the dominant multi-resistant strain (AUS-2/3-like) declined from 29.6% to 3.4% during the study period (P < 0.001), as did the rates of hospital origin MRSA in two of the major hospitals in the region.

              Conclusions: The prevalence of MRSA in the HNELHD region decreased during the study period, and was predominantly acquired in the community, particularly by young people, Indigenous Australians, and residents of aged care facilities. While the dominance of the multi-resistant strain decreased, new strategies for controlling infections in the community are needed to reduce the prevalence of non-multi-resistant strains.

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              • 1 Australian National University Medical School, Australian National University, Canberra, ACT
              • 2 John Hunter Hospital, Newcastle, NSW
              • 3 University of Newcastle, Newcastle, NSW
              • 4 NSW Health Pathology, Newcastle, NSW
              • 5 Hunter New England Health, Newcastle, NSW
              • 6 National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT


              Correspondence: jason.agostino@anu.edu.au
              Competing interests:

              No relevant disclosures.

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                The kids are OK: it is discrimination not same-sex parents that harms children

                Ken W Knight*, Sarah EM Stephenson*, Sue West*, Martin B Delatycki, Cheryl A Jones, Melissa H Little, George C Patton, Susan M Sawyer, S Rachel Skinner, Michelle M Telfer, Melissa Wake, Kathryn N North and Frank Oberklaid
                Med J Aust 2017; 207 (9): . || doi: 10.5694/mja17.00943
                Published online: 23 October 2017

                An update on the evidence, and implications for the medical community

                The current public debate about same-sex marriage raises a number of significant issues for medical professionals and researchers in Australia. Misinformation is circulating in the public domain that children and adolescents with same-sex parents are at risk of poorer health and wellbeing than other children. An increased public health risk exists as a result of homophobic campaign messages for the entire lesbian, gay, bisexual, transgender, intersex and queer (LGBTIQ+) community, including a mental health risk for same-sex couples, their children, and young people who identify as LGBTIQ+.


                • 1 Murdoch Childrens Research Institute, Melbourne, VIC
                • 2 University of Melbourne, Melbourne, VIC
                • 3 Royal Children's Hospital, Melbourne, VIC
                • 4 Victorian Clinical Genetics Services, Melbourne, VIC
                • 5 Children's Hospital at Westmead, Sydney, NSW
                • 6 Liggins Institute, University of Auckland, Auckland, NZ


                Correspondence: frank.oberklaid@rch.org.au

                * Joint first authors 

                Competing interests:

                No relevant disclosures.

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                Online responses are no longer available. Please refer to our instructions for authors page for more information.

                  Reducing antibiotic prescribing in Australian general practice: time for a national strategy

                  Christopher B Del Mar, Anna Mae Scott, Paul P Glasziou, Tammy Hoffmann, Mieke L van Driel, Elaine Beller, Susan M Phillips and Jonathan Dartnell
                  Med J Aust 2017; 207 (9): . || doi: 10.5694/mja17.00574
                  Published online: 23 October 2017

                  Summary

                   

                  • In Australia, the antibiotic resistance crisis may be partly alleviated by reducing antibiotic use in general practice, which has relatively high prescribing rates — antibiotics are mostly prescribed for acute respiratory infections, for which they provide only minor benefits.
                  • Current surveillance is inadequate for monitoring community antibiotic resistance rates, prescribing rates by indication, and serious complications of acute respiratory infections (which antibiotic use earlier in the infection may have averted), making target setting difficult.
                  • Categories of interventions that may support general practitioners to reduce prescribing antibiotics are: regulatory (eg, changing the default to “no repeats” in electronic prescribing, changing the packaging of antibiotics to facilitate tailored amounts of antibiotics for the right indication and restricting access to prescribing selected antibiotics to conserve them), externally administered (eg, academic detailing and audit and feedback on total antibiotic use for individual GPs), interventions that GPs can individually implement (eg, delayed prescribing, shared decision making, public declarations in the practice about conserving antibiotics, and self-administered audit), supporting GPs’ access to near-patient diagnostic testing, and public awareness campaigns.
                  • Many unanswered clinical research questions remain, including research into optimal implementation methods.
                  • Reducing antibiotic use in Australian general practice will require a range of approaches (with various intervention categories), a sustained effort over many years and a commitment of appropriate resources and support.

                   


                  • 1 Centre for Research in Evidence-Based Practice, Bond University, Gold Coast, QLD
                  • 2 University of Queensland, Brisbane, QLD
                  • 3 Therapeutic Guidelines, Melbourne, VIC
                  • 4 NPS MedicineWise, Sydney, NSW


                  Correspondence: CDelMar@bond.edu.au
                  Acknowledgements: 

                  We received funds from the National Health and Medical Research Council for the Centre for Research Excellence in Minimising Antibiotics in Acute Respiratory Infections in Primary Care.

                  Competing interests:

                  We have been commissioned by the Australian Commission for Safety and Quality and Health Care and Bupa to provide expertise and to design patient decision aids.

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                  Online responses are no longer available. Please refer to our instructions for authors page for more information.

                    Cardiac Society of Australia and New Zealand position statement executive summary: coronary artery calcium scoring

                    Christian R Hamilton-Craig, Clara K Chow, John F Younger, V M Jelinek, Jonathan Chan and Gary YH Liew
                    Med J Aust 2017; 207 (8): . || doi: 10.5694/mja16.01134
                    Published online: 16 October 2017

                    Summary

                    Introduction

                    This article summarises the Cardiac Society of Australia and New Zealand position statement on coronary artery calcium (CAC) scoring. CAC scoring is a non-invasive method for quantifying coronary artery calcification using computed tomography. It is a marker of atherosclerotic plaque burden and the strongest independent predictor of future myocardial infarction and mortality. CAC scoring provides incremental risk information beyond traditional risk calculators such as the Framingham Risk Score. Its use for risk stratification is confined to primary prevention of cardiovascular events, and can be considered as individualised coronary risk scoring for intermediate risk patients, allowing reclassification to low or high risk based on the score. Medical practitioners should carefully counsel patients before CAC testing, which should only be undertaken if an alteration in therapy, including embarking on pharmacotherapy, is being considered based on the test result.

                    Main recommendations

                    • CAC scoring should primarily be performed on individuals without coronary disease aged 45–75 years (absolute 5-year cardiovascular risk of 10–15%) who are asymptomatic.
                    • CAC scoring is also reasonable in lower risk groups (absolute 5-year cardiovascular risk, < 10%) where risk scores traditionally underestimate risk (eg, family history of premature CVD) and in patients with diabetes aged 40–60 years.
                    • We recommend aspirin and a high efficacy statin in high risk patients, defined as those with a CAC score ≥ 400, or a CAC score of 100–399 and above the 75th percentile for age and sex.
                    • It is reasonable to treat patients with CAC scores ≥ 100 with aspirin and a statin.
                    • It is reasonable not to treat asymptomatic patients with a CAC score of zero.

                    Changes in management as a result of this statement

                    • Cardiovascular risk is reclassified according to CAC score.
                    • High risk patients are treated with a high efficacy statin and aspirin.
                    • Very low risk patients (ie, CAC score of zero) do not benefit from treatment.

                     


                    • 1 Heart and Lung Institute, The Prince Charles Hospital, Brisbane, QLD
                    • 2 Centre for Advanced Imaging, University of Queensland, Brisbane, QLD
                    • 3 The George Institute for Global Health, Sydney, NSW
                    • 4 Westmead Hospital, Sydney, NSW
                    • 5 Royal Brisbane and Women's Hospital, Brisbane, QLD
                    • 6 St Vincent's Hospital, Melbourne, VIC
                    • 7 Cardiovascular Research Centre, Australian Catholic University, Melbourne, VIC
                    • 8 Griffith University, Gold Coast, QLD
                    • 9 Gold Coast Heart Centre, Gold Coast, QLD
                    • 10 University of Adelaide, Adelaide, SA
                    • 11 Epworth HealthCare, Melbourne, VIC


                    Correspondence: c.hamiltoncraig@uq.edu.au
                    Competing interests:

                    No relevant disclosures.

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                    • 21. Miedema MD, Duprez DA, Misialek JR, et al. Use of coronary artery calcium testing to guide aspirin utilization for primary prevention: estimates from the multi-ethnic study of atherosclerosis. Circ Cardiovasc Qual Outcomes 2014; 7: 453-460.
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                    • 23. Raggi P, Callister TQ, Shaw LJ. Progression of coronary artery calcium and risk of first myocardial infarction in patients receiving cholesterol-lowering therapy. Arterioscler Thromb Vasc Biol 2004; 24: 1272-1277.
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                    Online responses are no longer available. Please refer to our instructions for authors page for more information.

                      Atopic dermatitis: the new frontier

                      Victoria R Harris and Alan J Cooper
                      Med J Aust 2017; 207 (8): . || doi: 10.5694/mja17.00463
                      Published online: 16 October 2017

                      Summary

                       

                      • Atopic dermatitis (AD) is the most common inflammatory skin condition in adults and children.
                      • AD is a chronic disease that has a considerable negative impact on the quality of life of patients and their families.
                      • Most cases of AD may be effectively treated with topical therapies that are directed at decreasing cutaneous inflammation and alleviating pruritus. These therapies include emollients, antihistamines, topical corticosteroids, topical calcineurin inhibitors and antimicrobial and antiseptic measures; more refractory cases may require additional oral immunosuppression (eg, cyclosporine, azathioprine, methotrexate and mycophenolate).
                      • Improved understanding of the immune pathogenesis of AD, including the role of T helper cells and the inflammatory pathways involved, has led to breakthrough translational clinical research and treatment.
                      • New targeted immunotherapies, such as inhibitors of interleukin (IL)-4, IL-13, IL-31, Janus associated kinase and phosphodiesterase, have had promising results from phase 2 and 3 trials for patients with moderate to severe AD.

                       


                      • Royal North Shore Hospital, Sydney, NSW


                      Competing interests:

                      No relevant disclosures.

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