Pulmonary cryptococcosis describes an invasive lung mycosis caused by Cryptococcus neoformans or Cryptococcus gattii complex. It is often a high-consequence disease in both immunocompromised and immunocompetent populations, and may be misdiagnosed as pulmonary malignancy, leading to a delay in therapy. Epidemiology follows that of cryptococcal meningoencephalitis, with C. gattii infection more common in certain geographic regions. Diagnostic tools include histopathology, microscopy and culture, and the detection of cryptococcal polysaccharide antigen or Cryptococcus-derived nucleic acids. All patients with lung cryptococcosis should have a lumbar puncture and cerebral imaging to exclude central nervous system disease. Radiology is key, both as an adjunct to laboratory testing and as the initial means of detection in asymptomatic patients or those with non-specific symptoms. Pulmonary cryptococcomas (single or multiple) may also be associated with disseminated disease and/or cryptococcal meningitis, requiring prolonged treatment regimens. Optimal management for severe disease requires extended induction (amphotericin B and flucytosine) and consolidation therapy (fluconazole) with close clinical monitoring. Susceptibility testing is of value for epidemiology and in regions where relatively high minimum inhibitory concentrations to azoles (particularly fluconazole) have been noted. Novel diagnostic tools and therapeutic agents promise to improve the detection and treatment of cryptococcosis, particularly in low-income settings where the disease burden is high.

Flaviviruses are a diverse group of enveloped RNA viruses that cause significant clinical manifestations in the pregnancy and postpartum periods. This review highlights the epidemiology, pathophysiology, clinical features, diagnosis, and prevention of the key arthropod-borne flaviviruses of concern in pregnancy and the neonatal period—Zika, Dengue, Japanese encephalitis, West Nile, and Yellow fever viruses. Increased disease severity during pregnancy, risk of congenital malformations, and manifestations of postnatal infection vary widely amongst this virus family and may be quite marked. Laboratory confirmation of infection is complex, especially due to the reliance on serology for which flavivirus cross-reactivity challenges diagnostic specificity. As such, a thorough clinical history including relevant geographic exposures and prior vaccinations is paramount for accurate diagnosis. Novel vaccines are eagerly anticipated to ameliorate the impact of these flaviviruses, particularly neuroinvasive disease manifestations and congenital infection, with consideration of vaccine safety in pregnant women and children pivotal. Moving forward, the geographical spread of flaviviruses, as for other zoonoses, will be heavily influenced by climate change due to the potential expansion of vector and reservoir host habitats. Ongoing ‘One Health’ engagement across the human-animal-environment interface is critical to detect and responding to emergent flavivirus epidemics.

Background: Bacteraemia is associated with high morbidity and mortality, with delayed antibiotic treatment associated with poorer outcomes. Early identification is challenging, but clinically important. Multiple scoring systems have been developed to identify individuals in the broader categories of sepsis. We designed this study to assess the performance of existing scoring systems and pathways—CEC SEPSIS KILLS pathway (an Australian sepsis care package), quick sequential organ failure score (qSOFA), systemic inflammatory response syndrome (SIRS) and the Shapiro criteria. Methods: This was a retrospective cohort study performed in two metropolitan hospitals in NSW, consisting of adult patients (> 18 years) with positive blood cultures containing a true pathogen and patients matched by age without positive blood cultures. Performance (sensitivity, specificity, and mortality prediction) of recognised sepsis and bacteraemia criteria and pathways—qSOFA, SIRS, Shapiro criteria and CEC SEPSIS KILLS pathway in the first 4 h following ED triage was assessed. Results: There were 251 patients in each cohort. Sepsis-related mortality was higher in the bacteraemic group (OR 0.4, p = 0.03). Of the criteria studied, the modified Shapiro criteria had the highest sensitivity (88%) with modest specificity (37.85%), and qSOFA had the highest specificity (83.67%) with poor sensitivity (19.82%). SIRS had reasonable sensitivity (82.07%), with poor sensitivity (20.72%). The CEC SEPSIS pathway sensitivity of 70.1% and specificity of 71.1%. The SEPSIS KILLS was activated on only 14% of bacteraemic patients. Conclusion: The performance of all scoring systems and pathways was suboptimal in the identification of patients at risk of bacteraemia presenting to the emergency department.

Background Bacteraemia is associated with high morbidity and mortality, with delayed antibiotic treatment associated with poorer outcomes. Early identification is challenging, but clinically important. Multiple scoring systems have been developed to identify individuals in the broader categories of sepsis. We designed this study to assess the performance of existing scoring systems and pathways - CEC SEPSIS KILLS pathway, quick sequential organ failure score (qSOFA), systemic inflammatory response syndrome (SIRS) and the Shapiro criteria. Methods This was a retrospective cohort study performed in two metropolitan hospitals in NSW, consisting of adult patients (>18 years) with positive blood cultures containing a true pathogen and patients matched by age without positive blood cultures. Performance (sensitivity, specificity, and mortality prediction) of recognised sepsis and bacteraemia criteria and pathways - qSOFA, SIRS, Shapiro criteria and CEC SEPSIS KILLS pathway in the first 4 hours following ED triage was assessed. Results There were 251 patients in each cohort. Sepsis-related mortality was higher in the bacteraemic group (OR 0.4, p=0.03). Of the criteria studied, the modified Shapiro criteria had the highest sensitivity (88%) with modest specificity (37.85%), and qSOFA had the highest specificity (83.67%) with poor sensitivity (19.82%). SIRS had reasonable sensitivity (82.07%), with poor sensitivity (20.72%). The CEC SEPSIS pathway sensitivity of 70.1% and specificity of 71.1%. The SEPSIS KILLS was activated on only 14% of bacteraemic patients. Conclusion The performance of all scoring systems and pathways was suboptimal in the identification of patients at risk of bacteraemia presenting to the emergency department.

Existing therapeutic options are limited for severe methicillin-resistant Staphylococcus aureus (MRSA) infections. Newer antimicrobials with anti-MRSA activity have been introduced, but evaluation of pre-existing resistance in the Australian setting is limited. Our objectives are to characterise the antimicrobial susceptibility profile of the common MRSA sequence types (STs) in Australia relating to newer antimicrobial agents to determine the association between non-susceptibility and ST, trends in minimum inhibitory concentration (MIC) for antimicrobial classes, and genomic associations with resistance phenotypes. One-hundred clinical MRSA isolates were selected, representing the ten most common ST clones determined by national surveillance data in Australia. MIC was determined for ceftaroline, ceftobiprole, tedizolid, dalbavancin, eravacycline, omadacycline, delafloxacin, lefamulin and vancomycin. The associations between non-susceptibility and common resistance mechanisms for the isolates were characterised by whole-genome sequencing. All isolates were susceptible to ceftaroline, ceftobiprole, dalbavancin, eravacycline, tedizolid, and vancomycin. Thirty-nine isolates, comprising all ST239, PVL-negative ST22 and ST45 isolates, eight of ten ST8 isolates and one of ten ST78 isolates, were resistant to delafloxacin (when community-acquired-pneumonia site-specific breakpoints were applied). One isolate of ST239 was resistant to lefamulin, and two isolates of ST1 had elevated omadacycline MIC. There was a correlation between delafloxacin non-susceptibility and known associated mutations. Newer Gram-positive antimicrobial agents, apart from delafloxacin, demonstrate good in vitro activity against Australian MRSA STs. Susceptibility testing prior to use of delafloxacin, lefamulin and omadacycline should be considered. When the use of these agents becomes commonplace, ongoing monitoring for resistance is recommended.