FEDERATION OF
infection societies
CONFERENCE 2018

13th – 15th November 2018 | Sage Gateshead – Newcastle

FEDERATION OF
infection societies
CONFERENCE 2018

13th – 15th November 2018 | Sage Gateshead – Newcastle

FEDERATION OF
infection societies
CONFERENCE 2018

13th – 15th November 2018 | Sage Gateshead – Newcastle

Posters

VIRAL HEPATITIS & GENERAL VIROLOGY – Poster Nos. 086-093

086
Clinical and economic impact of point-of-care test for influenza in the Emergency Department

Abstract - 086

Poster 086

Clinical and economic impact of point-of-care test for influenza in the Emergency Department

Shabnam Iyer1, Steffan Glaze1, Live Thorsen1, Jo Jefferies2
1Royal Berkshire NHS Foundation Trust, Reading. 2Public Health Services for Berkshire, Reading

Introduction: The winter influenza season is a significant challenge to the capacity of the NHS. Accurate and rapid diagnosis of influenza at the point of care allows timely and effective administration of anti-viral therapy, reduction in inappropriate antibiotic use and prevents nosocomial transmission by facilitating prompt and targeted patient isolation. Point of care tests (POCT) for influenza provide the capability for rapid diagnosis in a patient care environment when no clinical laboratory facility is immediately available. Previous influenza antigen detection POCTs have lacked sufficient sensitivity or specificity, but new PCR based POCTs are comparable to laboratory-based methods.

During the 2017-18 influenza season, Cobas Liat (lab in a tube) Influenza A/B (Roche Diagnostics, Indianapolis, IN), a rapid point of care PCR test for the detection of influenza A and B viruses, was evaluated in the Emergency Department (ED) at the Royal Berkshire Hospital, Reading, UK, and its clinical and economic impact assessed.

Methods: Patients presenting in the ED with symptoms and signs of influenza like illness or a clinical illness compatible with complication of influenza, and requiring admission to the hospital were tested for influenza in the ED with the Cobas Liat influenza A/B POCT. The clinical and health economic impact of ED Influenza POCT was assessed by undertaking the retrospective analysis of the case notes review of 100 influenza cases and comparing the length of stay and prescription of anti-viral and antibiotics with those tested using the standard lab-based influenza PCR testing.

Results: Compared with the standard lab-based influenza PCR testing, ED Influenza POCT use resulted in: 

  • Earlier diagnosis of influenza and administration of anti-viral therapy
  • 3 day reduction in median length of stay
  • Reduction in duration and number of antibiotics prescribed
  • Significant savings in healthcare resources despite higher test costs

Discussion: Influenza POCT in the Emergency Department of an acute hospital provides the opportunity for earlier and more effective identification and treatment of influenza cases, offering clinical and economic benefits to patients and organisations. Use of influenza POCT in other clinical settings, such as general practices and nursing homes may reduce the overall burden of seasonal influenza on individuals and the NHS. 

087
Disseminated adenovirus Type 7 infection causing acute respiratory distress in immunocompetent adults: a case series from an intensive care unit in North West England

Abstract - 087

Poster 087

Disseminated adenovirus Type 7 infection causing acute respiratory distress in immunocompetent adults: a case series from an intensive care unit in North West England

Tom Wingfield1,2,3,4, Luke Dearden1, Pete Calvert1, Orod Osanlou1, Brian Johnston1, Anu Chawla1, Ian Hart1, Lance Turtle1,4, Richard Wenstone1
1Royal Liverpool and Broadgreen University Hospitals NHS Trust. 2Karolinska Institutet, Stockholm, Sweden. 3Liverpool School of Tropical Medicine. 4University of Liverpool

Introduction: Disseminated adenovirus disease, especially related to adenovirus Type 7, is well described in immunocompromised hosts and can cause significant morbidity and mortality. Rarely, it also affects immunocompetent hosts.

Methods: We describe a case series of disseminated adenovirus disease in immunocompetent hosts admitted to an intensive care unit in a large, teaching hospital in North West England. The cases were not associated with any known, local outbreaks. We compare and contrast the clinical presentation, radiological and virological features of the cases and provide a concise review of the literature.

Results: Case 1: In January 2018, a 35-year-old HIV-negative female with mild asthma, obesity, and schizophrenia presented with a 4-day history of flu-like illness, dyspnoea, and a productive cough. Initial evaluation revealed severe respiratory distress and widespread wheeze. Investigations showed lymphopenia with raised inflammatory markers, type 1 respiratory failure, and patchy consolidation bilaterally on chest radiograph. She was treated for a life-threatening exacerbation of asthma, suspected influenza, and community-acquired pneumonia. Despite treatment, she deteriorated and, on Day 4, was transferred to ICU for intubation. On day 5, diagnostic bronchoscopy with lavage (BAL) was performed. On day 8, BAL and EDTA plasma returned a strongly positive adenovirus (5.8 X 108 gEq/ml and 9.5 X 106 gEq/ml, respectively), which was identified by genomic sequencing as Species B, Type 7, and once-weekly cidofovir was commenced. No other viral and/or bacterial pathogens were isolated. She improved over the next two months and was de-escalated to ward-level care on day 65.

Case 2: In April 2018, a fit 73-year-old male presented with a 3-day history of gastroenteritis and lethargy without respiratory symptoms. On examination, he was hypotensive and pyrexial. Investigations showed lymphopenia, left middle-zone consolidation on chest radiograph, and he was treated for community-acquired pneumonia. By day 6, he deteriorated and required transfer to ICU for intubation. A chest CT demonstrated left-sided consolidation with bilateral pleural effusions and he underwent bronchoscopy with BAL. On day 8, throat swab, BAL and EDTA plasma returned strong positives adenovirus (7.5 X 109 gEq/ml and 2.0 X 106 gEq/ml, respectively), which was identified by genomic sequencing as Species B, Type 7, and a single dose of cidofovir was given. No other bacterial or viral pathogens were isolated. By day 12, he had multi-organ failure and life-sustaining treatment was withdrawn.

Discussion: Human adenoviruses are non-enveloped DNA viruses of the Adenoviridae family grouped into 7 species (A to G) and consisting of over 70 types. They are associated with infections of the respiratory and gastrointestinal epithelial tissues. Disseminated adenoviral disease, especially related to adenovirus Type 7, can cause significant morbidity and mortality.It is well recognised in immunocompromised patients but uncommon in immunocompetent hosts, occurring mainly in outbreaks amongst individuals living in close proximity.

The rare cases we report highlight that clinical and radiological features of disseminated adenovirus affecting the respiratory system are similar to other infective causes of pneumonia and ARDS, including severe influenza. This can create diagnostic uncertainty especially during peak periods of seasonal influenza, such as in Case 1.

Adenovirus identification is best achieved by PCR and, in patients with a clinically compatible syndrome and no other identified aetiology, a positive adenovirus PCR results can support diagnosis.

Although treatment is predominantly supportive, early use of cidofovir may improve outcomes. However, its use is limited by nephrotoxicity. There is no evidence for IVIG in adenovirus infections but it was given to Patient 2 due to biologically-plausible benefit of providing adenovirus-directed antibodies.

These rare cases highlight that disseminated adenovirus infection should be considered in the differential diagnoses of immunocompetent patients presenting with pneumonia and ARDS.  

088
Pilot study for introduction of point of care (POC) rapid molecular testing of respiratory viruses at a remote District General Hospital during the winter season 2017-18

Abstract - 088

Poster 088

Pilot study for introduction of point of care (POC) rapid molecular testing of respiratory viruses at a remote District General Hospital during the winter season 2017-18

Annika Graham, Noha ElSakka
NHS Grampian, Aberdeen

Introduction: Doctor Gray’s Hospital (DGH) is a 185-bed district general hospital located in Elgin, 65 miles to the north of Aberdeen. Respiratory samples from DGH are transferred to Aberdeen Royal Infirmary (ARI) by courier system with long transport time, and respiratory testing is performed by in house PCR at ARI virology department. Service is available 6 days a week (Mon-Sat). Incoming respiratory samples are batched with a cut off time of 09:30 AM. Any samples received after that are delayed until the next day’s run, experiencing a delay of a further 24 hours. Turnaround time (TAT) can vary between 8 hrs – 48 hrs from sample arrival in the lab. The in-house test covers 15 pathogenic targets. There is a clinical need to reduce the TAT and to extend the pathogen coverage to a wider number of targets.

Methods: We conducted a pilot study of introducing a respiratory point of care system (POC) at DGH acute medical admission ward during the busy winter season 2017-18. The system used (GenMark e-Plex RP) is a rapid molecular PCR for detection of respiratory viruses (20 viruses) in addition to atypical bacterial pathogens (4 Bacterial targets). Results are available within 90 minutes. 

The system requires minimal skills, and training was provided to medical and nursing staff at acute medical admission, however, the system was set to serve all the wards of the hospital. 

The e-Plex system allowed for on-demand, random-access flexibility, to help decisions on bed management, early discharge, promote patient flow infection control management.

Respiratory samples were double tested (ARI and DGH POCT) during the study period 

Results: A total of 114 samples were tested by POCT at DGH during the period of 21st Dec 2017-end of March 2018. The maximum number of samples were in February (44 samples). Positive Flu A were 24 samples (21%), Flu B 17 samples (15%) and 61 samples were negative (54%). There was no atypical pneumonia detected. The main reason for testing was mainly suspected flu or URTI. During the same period 330 samples were sent to ARI for respiratory testing. Of which 66 samples were positive for Flu A (20%), 30 samples were positive for Flu B (9%), one positive mycoplasma pneumonia and 192 sample were negative (58%). The average TAT for results of samples in ARI was 2.1 days, with 23 samples took 4-5 days TAT.

Data for infection control precautions were available for 67 patients, of which 7 patients were in the open ward were moved to isolation following the POCT result.

Discussion: The use of on-site POCT in DGH allowed an opportunity to identify and deal with circulating flu earlier, raising awareness and isolating early (many of the patients were elderly with comorbid and presented relatively non-specifically with delirium and exacerbations of existing respiratory conditions, but also febrile). 

Samples tested in ARI had an average high TAT that was significantly reduced by the rapid provision of results on site by the POCT. This helped patient flow and control of respiratory outbreaks.

Atypical infection does not appear to be a major problem in the local community at DGH during the winter season, only one case was found positive with mycoplasma of 330 cases.

089
Introduction of rapid molecular testing of respiratory viruses at acute medical admission during the winter season 2017-18

Abstract - 089

Poster 089

Introduction of rapid molecular testing of respiratory viruses at acute medical admission during the winter season 2017-18

Robin Brittain-Long, Noha Elsakka
NHS Grampian, Aberdeen

Introduction: Respiratory Tract Infections cause significant clinical and economic burden to NHS Grampain patients and Trust. Diagnosis based on clinical symptoms alone is extremely difficult and often inaccurate. Conventional Algorithm Delays Diagnosis and Treatment and Increases Hospital Costs.

Rapid and accurate diagnosis of respiratory viruses is critical for clinical management and infection control measures in healthcare settings. In addition, receiving early treatment is associated with better outcome.

From previous experience through the winter seasons, delay in diagnosis of respiratory tract infection has risk of transmission of infection to other patients and staff, chances of outbreaks and ward closure which is detrimental during the high pressure winter season.

Acute medical admission (AMIA) is the main point of entry of patients with respiratory tract infection in ARI. This is subject to increase to a highest peak during winter putting a high pressure on the labs, wards and the hospital bed management. There is a pressing demand to get a rapid diagnosis of respiratory tract infections. 

Methods: We conducted a pilot study for verification of POC molecular testing pathway in AMIA. This type of virology molecular POCT has not been evaluated in the clinical wards in ARI before.

A rapid molecular POC system was introduced at AMIA on the 21stof December 2017. The system used (GenMark e-Plex RP) is a rapid molecular PCR for detection of respiratory viruses and atypical bacterial respiratory pathogens providing result within 90 minutes. The e-Plex system allowed for on-demand, random-access flexibility, to help decisions on bed management, early discharge, promote patient flow infection control management.

Respiratory samples were double tested (ARI and AMIA POCT) during the study period

Results: A total of 673 samples were tested by POCT at AMIA during the period of 21st Dec 2017-end of April 2018. Positive Flu A were 164 samples (24%), Flu B 75 samples (11%) and 312 samples were negative (46%). During the same period 941 samples were sent to ARI for respiratory testing. Of which 185 samples were positive for Flu A (20%), 101 samples were positive for Flu B (11%) and 585 sample were negative (62%). The average TAT for results of samples in ARI was 1.2 

Discussion: The use of on-site POCT in AMIA allowed an opportunity to identify and deal with circulating flu earlier, raising awareness and isolating early (many of the patients were elderly with comorbid and presented relatively non-specifically with delirium and exacerbations of existing respiratory conditions, but also febrile).

Samples tested in ARI had an average high TAT that was significantly reduced by the rapid provision of results on site by the POCT. This helped patient flow and control of respiratory outbreaks

090
Nanopore detection of influenza virus direct from respiratory samples

Abstract - 090

Poster 090

Nanopore detection of influenza virus direct from respiratory samples

Kuiama Lewandowski1, Yifei Xu2,3, Sheila Lumley4,5, Ali Vaughan3, Richard Vipond1, Miles Carroll1, Sarah Walker3, Peter Simmonds5, Dona Foster3, Tim Peto4,3,2, Derrick Crook3,2,4, Philippa Matthews5,4, Steven Pullan1
1Public Health England, National Infection Service, Porton Down. 2Nuffield Department of Medicine, University of Oxford. 3NIHR Oxford Biomedical Research Centre, University of Oxford. 4 Infectious Diseases and Microbiology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford. 5Nuffield Department of Medicine, Peter Medawar Building for Pathogen Research, University of Oxford

Introduction: Each year, influenza places a significant burden on healthcare systems and societies globally, with clinical and socioeconomic consequences. Real-time sequencing of full length influenza virus, facilitates rapid diagnosis, permits identification of circulating subtypes, and has potential to improve antimicrobial stewardship, patient admissions and discharges, predicting vaccine effectiveness, detecting antiviral drug resistance, and characterising transmission networks.

The portability, footprint and real-time nature of Nanopore platforms facilitates sequencing as a near-to-patient test for infectious diseases. This project aims to develop a Nanopore sequencing solution to detect and provide complete sequences of Influenza virus from patient throat swabs. 

Methods:

  1. Sample selection

We used pooled viral transport medium from 40 Influenza A positive and 40 Influenza A/B negative throat swabs (tested by Biofire respiratory panel in a clinical diagnostic lab).

  1. Method optimisation

The sequencing protocol was based on previous Public Health England experience of direct sequencing of RNA viruses from serum/plasma. Pooled samples were spiked with a control virus (Hazara virus, at 10^4 copies /ml) and filtered through a 0.45µm membrane prior to RNA extraction and DNAse treatment. Reverse-transcription and amplification was performed using sequence-independent single-primer amplification (SISPA). Multiplexed libraries were sequenced on the Nanopore GridION. Reads were classified by Centrifuge, mapped using minimap2, binned to species level and de novo assembled using Canu and Nanopolish.

  1. a) The efficacy of filtration vs a high speed spin were compared to find the optimal protocol for reducing bacterial and human nucleic acid background.
  2. b) The time for sample preparation was optimised, by decreasing PCR elongation time from five to two minutes.
  3. Defining limit of detection

A triplicate dilution range was used to assess the limit of detection. The Influenza A positive pool (10^6 Influenza A copies/ml) was diluted to 10^4, 10^3 and 10^2 copies/ml in triplicate using 3 different pools of negative throat swab. Hazara virus internal control was spiked into each sample at 10^4 copies/ml.

Results: We have successfully established a workflow for detection of Influenza A virus from throat swabs using Nanopore, which allows us to consistently detect Influenza A and reconstruct full length genomes with higher viral load samples.  We were also able to detect other RNA respiratory viruses including RSV, rhinovirus and metapneumovirus.

The limit of detection for consistent detection of Influenza reads was 103 genome copies/ml in the original sample. Genome coverage is dependent on the background non-viral nucleic acid content of the sample. Input of 104 genome copies/ml (in the original sample) permitted near full genome 1x coverage and 75% and 87% genome respectively at 5x coverage (required for HA/NA subtyping) in 2 out of 3 pools. Input of 106 genome copies/ml (in the original sample) gave full or >99% genome at 5x coverage (required for confident base calling/SNP typing) for all pools.

Filtration and highspeed spin are comparable approaches to remove background nucleic acid. The shortened protocol is suitable, with elongation time of 2 minutes (total protocol time reduced from 6h45 to 4h).

Discussion: We have successfully established a laboratory protocol for detection of Influenza A virus from throat swabs using Nanopore. Further work is required to determine the limit of detection for Influenza A in individual patients, and for Influenza B. The aim is to evaluate the Nanopore method head to head with the diagnostic PCR in the upcoming flu season at a large tertiary referral clinical microbiology lab. These findings provide a blueprint for the eventual use of Nanopore as a diagnostic tool for influenza detection.

091
Setting up point of care testing for influenza and RSV on the Acute Admissions Unit of a Tertiary Referral Hospital; experience of three years of testing

Abstract - 091

Poster 091

Setting up point of care testing for influenza and RSV on the Acute Admissions Unit of a Tertiary Referral Hospital; experience of three years of testing

Shirelle Burton-Fanning, Sheila Waugh, Ashley Price, Jayne Harwood, Brendan Payne, Chris Gibbins
Newcastle upon Tyne Hospitals NHS Foundation Trust

Introduction: Influenza infections can pose a significant healthcare burden during winter months. UK guidance advises that patients with suspected influenza are isolated to reduce transmission, and where indicated, antiviral treatment should be started within 48 hours of presentation. Empiric isolation can be challenging where isolation capacity is limited and as patients may not present with a classic influenza like illness. Point of care testing can identify patients earlier in their admission who require isolation and treatment and also enable earlier discharge.

We describe the process of introducing a commercial molecular assay as a point of care test (POCT) in the medical assessment suite and its use for the past three respiratory seasons.

Methods: An audit of patient with influenza in 2014/15 indicated only 41% of patients admitted to the assessment suite were empirically isolated. Discussions with the Director of Infection Prevention and Control, clinical lead of the assessment suite, healthcare scientist for virology and consultant virologists identified the possibility of POCT improving the management of patients with influenza and reducing the exposure to susceptible contacts. The Cepheid GeneExpertTM analyser had previously been used within the laboratory to provide urgent testing. This platform was identified as suitable for near patient testing. A successful business case was submitted which enabled the analyser (on loan from the Public Health England Laboratory North East) to be placed in a designated testing area on the AS. This method had previously been validated by the laboratory. In the first year it was felt junior medical staff in the unit should be trained to perform the test. This was expanded to nursing staff and healthcare assistants in subsequent years. Standard operating procedures for the collection and analysis of the samples and written guidance on the management of patient and their contacts were provided. Training was provided by the healthcare scientist for virology who also provided support through the seasons to trouble shoot any issues with the analyser. A proportion of samples were tested in parallel with the laboratory assay to ensure concordance.

Results

  • POCT positivity rate was between 20-40% throughout most of the seasons.
  • Parallel testing of a proportion of samples showed good concordance with the laboratory assay.
  • In 2015/2016
    • Influenza results were available a median of 1 day 9 hours earlier by POCT
    • Antivirals were prescribed a median of 1 day 4 hours earlier for patients with influenza.
    • Patients were isolated a median of 12 hours earlier
  • In 2017/2018
    • For patients tested in ED or the Assessment Suite, 43% of influenza patients were discharged within 24hrs of admission in comparison to 20% in 2014/15

Discussion: POCT for influenza in the assessment suite is beneficial in the management of influenza infections with improved the isolation of patients and enables patients to be discharged earlier. In busy respiratory seasons POCT also enable cohorting of patients where necessary.

Inter-departmental collaboration was essential for the success of introducing testing. Audit of testing and isolation of patients supported the business case. Evaluation of the impact of testing enabled continued use of POCT in subsequent years.

We were aware of four sample identity errors in 2015/16 so modifications to the SOP were made to reduce this possibility in subsequent years.

As junior doctors rotated to different directorates, testing extended to patients on other wards. This has the potential to miss hospital acquired infections or outbreaks if the patient location is not accurately recorded. Developing a comprehensive SOP is vital to ensure appropriate infection control measures are in place and potential outbreaks are investigated and managed.

092
Evaluating the clinical efficacy of weekend flu testing at Chelsea and Westminster Hospital

Abstract - 092

Poster 092

Evaluating the clinical efficacy of weekend flu testing at Chelsea and Westminster Hospital

William Hurt1, Joshua Elliott1, Paul Randel2, Luke Moore1
1Chelsea Westminster Hospital, London. 2Imperial College London

Introduction: Chelsea Westminster Hospital commissions Flu testing from an off site centralised virology laboratory. Respiratory samples are routinely only tested during the working week (Monday – Friday). Due to the increase in clinical demand during the 2017/2018 winter flu season, Chelsea Westminster Hospital commissioned weekend flu testing, at a cost of £60/day, with an additional cost of £40 per test performed.

The aim of this audit was to analyse how weekend testing was implemented as well as to analyse the impact it had on both the clinical treatment of patients but also its utility in confirming who required ongoing isolation.

Methods: All respiratory virus PCR tests performed on a Saturday or Sunday were identified retrospectively using the master run files.

This data was cross referenced with routinely available data from electronic patient management software, which was used to identify the times of test requests and issued results, as well as tacking patient locations and the times patients were given medications.

This data was compared against a theoretical comparitor, in which we assumed no weekend testing took pace.  It was assumed that all results were reported at 16:45 on Monday in this group.

All data was saved to Microsoft Excel, denuded of patient identifying information and stored securely on an NHS authorised server. Descriptive patient data was generated using Microsoft Excel.

Results: 93 tests were performed over 12 weekends, equating to a total spend of £5,160. The average time from request, to issue of result was 27 hours, saving an average time to result of 39 hours/patient when compared to the Monday testing comparator.

23% (21/93) of patients tested positive for flu, 77% (72/93) tested negative. 86% (18/21) of positive results were from inpatients. 39% (7/18) of these were not isolated before results were issued. Of these 7 patients, weekend testing altered the management in 71% (5/7), with isolation occurring on average 32 hours earlier per patient versus the Monday comparator group. Saving a total of 161 patients hours during which flu positive patients would not have been isolated.

33% (7/21) of inpatients testing flu positive started treatment after the positive result was issued. This occurred on average 27 hours earlier in the weekend testing group versus the Monday comparator.

77% (72/93) tested negative, 92% (66/72) of these were inpatients, 41% (27/66) of whom were in isolation. After receiving a negative test result, only 11% (3/27) of patients were moved out of isolation. Weekend testing only altered management in one patient, saving only a total of 15 patient hours of side room use versus Monday testing.

17% (11/66) of flu negative inpatients were on treatment after result confirmation. Treatment was stopped in 45% (5/11) patients. A reduction the time on unnecessary therapy by an average of 19 hours/patient versus the comparator group. Equating to roughly 2 doses of Oseltamilvir per person or a total of 10 doses.

Discussion: This evaluation has shown that despite weekend testing leading to a saving of 39 hours to result per patient, the majority of these results were in accordance with the clinical diagnosis and so did not have the potential to alter management.

In the flu positive group, prevention of a a total of 161 patient/hours of potential infective exposure is a significant clinical benefit, and is likely the result of positive test results being called to clinicians by an infection specialist.

The greatest area of improvement and potential money saving is in actioning the de-isolation of patients who test negative. Only 15 hours of side room use were saved when there was the potential for over 900 hours to be saved.

 

093
Audit: Clinical and laboratory correlation of a detected Hepatitis A IgM antibody from a screening serology test

Abstract - 093

Poster 093

Audit: Clinical and laboratory correlation of a detected Hepatitis A IgM antibody from a screening serology test

Mihaela Petric, Joel Paul
Pennine Acute Trust, Royal Oldham Hospital, Microbiology/Virology Department, Manchester

Introduction: This audit was chosen to assess the outcome of a screening IgM HAV antibody result (equivocal, low level detected and high level detected) in comparison to the final result from the reference laboratory. The audit will evaluate the alternative clinical diagnoses that could have led to the low-level reactive HAV IgM antibody.
An automated laboratory comment will be proposed based on the cut-off value from the screening assay.

Methods: The screening IgM HAV antibody assay is tested in our lab using the Abbott Architect i2000 which uses a signal to cut-off ratio (S/CO) to report as not reactive, equivocal or reactive.

A total of 69 patients, audited during the period April 2015 – April 2018 at the microbiology lab in Pennine Acute NHS Trust were screened test equivocal or reactive for HAV IgM antibody.

The patients with these results were divided into two groups as follows:

(Group I)

Equivocal (S/CO of 0.8 to 1.2) & low level detected (S/CO of 1.2 to 3.0) for HAV IgM antibody = 28 patients

(Group II)

Detected at high level HAV IgM antibody (S/CO of >3.0) = 41 patients

All patients’ blood samples were sent to the Reference laboratory (Public Health England) for confirmation of HAV IgM antibody and further HAV RNA PCR.

Results: Among Group I patients, the majority had a final alternative clinical diagnosis such as hepatobiliary diseases, autoimmune diseases, malignancy, recent hepatitis A infection, neurological condition, pregnancy or an unknown diagnosis.

Among Group II patients, the majority presented clinically with jaundice (31/41) and had a final diagnosis of acute hepatitis A.

Of the Group I patients, the peak ALT ranged from 20 to 3970 IU/ml with a median of 88 IU/ml.

Of the Group II patients, the ALT ranged from 107 IU/ml to 6362 IU/ml with a median of 1476 IU/ml.

Of the Group I patients, the INR ranged from 1 to 3.5 with a median of 1.5

Of the Group II patients, the INR ranged from 1 to 10 with a median of 1.1

Of the 28 patients in Group I, blood samples were sent for confirmation to Reference Laboratory and final results showed only 3/28(≈10%) patients had acute hepatitis A infection.

Of the 41 patients in Group II, blood samples were sent for confirmation to Reference Laboratory and final results showed 40/41 (≈98%) patients had acute hepatitis A infection.

Discussion: As per our audit, patients in Group I were likely to have an acute hepatitis A infection confirmed as the final diagnosis only in 10% of cases. A laboratory comment for the HAV IgM test was designed as follows and proposed:

HEPATITIS ‘A’ SEROLOGY COMMENT:

The screening hepatitis A serology result is NOT highly suggestive of an acute hepatitis A infection. If patient has clinical and biochemical evidence of acute hepatitis, please send a repeat sample for a full viral hepatitis screen. Confirmatory reference lab results of this sample to follow.

As per our audit, patients in Group II were likely to have an acute hepatitis A infection confirmed as the final diagnosis in 98% of cases. A laboratory comment for the screening HAV IgM test was designed as follows and proposed:

HEPATITIS ‘A’ SEROLOGY COMMENT:

The screening hepatitis A serology result is highly suggestive of an acute hepatitis A infection. If patient has clinical and biochemical evidence of acute hepatitis, please send a repeat sample for confirmation and notify your local Health Protection Team. Confirmatory reference lab results of this sample to follow

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