Volume 211 Issue 3

Collaborative systems are required to combat the rising challenge of antimicrobial resistance in health care facilities and the community

Deborah A Williamson · Benjamin P Howden · David L Paterson

Antimicrobial resistance is a global problem that needs long term solutions and major resource investments

Joshua S Davis · Cheryl A Jones · Allen C Cheng · Benjamin P Howden

It' s time to move away from the viral versus bacterial dichotomy and embrace an evidencebased syndromic approach

Joshua S Davis · Parker J Magin · Mieke L Driel

The renewed program delivers a more personalised program for women by applying risk stratification

David C Currow · Sanchia Aranda

Interventions that encourage appropriate prescribing are required, including decision support systems and education about deprescribing

Robert FW Moulds · Dennis R McDermott

The renewed program is performing as expected during the initial HPV screening round

Dorothy A Machalek · Jennifer M Roberts · Suzanne M Garland · Julia Thurloe · Adele Richards · Ian Chambers · Terri Sivertsen · Annabelle Farnsworth

Culturally appropriate, targeted strategies are required for improving prescribing for older people in remote Aboriginal communities

Amy Page · Zoë Hyde · Kate Smith · Christopher Etherton‐Beer · David N Atkinson · Leon Flicker · Linda Skeaf · Roslyn Malay · Dina C LoGiudice

Reducing broad spectrum antibiotic use was associated with reduced VRE transmission and infection

John K Ferguson · Sally A Munnoch · Kristi Kozierowski · Simon Chiu · Christopher Oldmeadow

Increasing numbers of TGD individuals are seeking health care in Australia; new guidelines will help clinicians provide appropriate gender-affirming care

Ada S Cheung · Katie Wynne · Jaco Erasmus · Sally Murray · Jeffrey D Zajac

Routine and risk-based antenatal screening identifies some vertically transmissible infections that can be prevented or treated in pregnancy

Caitlin L Keighley · Hannah JM Skrzypek · Angela Wilson · Michael A Bonning · Gwendolyn L Gilbert

To the Editor: Writing recently in The Lancet, Byng and colleagues1 argue that our clinical guidelines on care of transgender children that appeared in the MJA2 use imprecise language, do not consider long term effects, and lack robust evidence. Several points the authors raise are valid and indeed align with what we and others have written about the state of evidence and need for high quality research in the field.3,4 However, it is important to provide additional clarification. First, the phrase “sex assigned at birth” is not intended to mislead as Byng and colleagues have claimed5 but is standard terminology for clinicians who work in transgender health (the guidelines’ primary intended audience).6 Second, the authors fail to acknowledge not only our direct call for more research on the guidelines’ opening page but also the detailed description of the long term effects of hormonal treatment, which is a key component of the guidelines.2 Moreover, in calling for more research, they ignore existing efforts to improve evidence in this field.7 Third, the authors raise the issue of de‐transition, which refers to the observation that some individuals who identify as transgender may eventually return to living as a member of their birth‐assigned sex. This subject has gained attention in mainstream media, which appears to be the authors’ source of information on this topic.5 While more research is needed, existing studies show true de‐transition is uncommon. For example, only 0.4% of 27 715 transgender people surveyed in the United States de‐transitioned because they felt transition was not right for them; more often, de‐transition occurred due to outside pressures (eg, parents, family, religion) and discrimination.8 In summary, Byng and colleagues’ call for more high quality research is not novel and has long been acknowledged by those of us in the field. Moreover, withholding gender‐affirming treatment via wait‐and‐see strategies mentioned by the authors is not without harm,9 and development and ongoing revision of guidelines such as ours will ensure that transgender individuals receive the best care based on up‐to‐date empirical evidence.

Ken C Pang · Carmen C Pace · Michelle A Tollit · Michelle M Telfer

To the Editor: Infective endocarditis with Staphylococcus aureus is associated with a high mortality despite optimal antibiotic therapy.1 The synergy between bacteriophages and antibiotics has been shown in vitro and in animal studies,2 and bacteriophages have demonstrated their value in severe bacterial infections.3 AB‐SA01 (AmpliPhi Biosciences) is a bacterial DNA‐free and protein‐free highly purified preparation of three obligately lytic Myoviridae, each at 109 plaque‐forming units per dose.4 This preparation has been recently used successfully for staphylococcal sinusitis by local irrigation.5 A protocol was established for bacteriophage therapy as an adjunct to standard care of severe staphylococcal infections under the auspices of the Therapeutic Goods Administration Special Access Scheme. Here, we report the first intravenous use of AB‐SA01 in a case of severe staphylococcal sepsis with prosthetic valve endocarditis. A 65‐year‐old man with a 30‐year‐old mechanical aortic valve presented with a week of malaise, severe exertional dyspnoea, and central pleuritic chest pain. He had been successfully treated for Haemophilus aphrophilus aortic valve endocarditis 8 years earlier with antibiotics alone. Examination revealed fever, tachypnoea, tachycardia and borderline hypotension (90–100 mmHg systolic), with a praecordial systolic murmur and click. There was no cardiac, renal or hepatic failure or any evident peripheral embolic sequelae of endocarditis (haematuria, splinter haemorrhages) at this stage. Blood cultures repeatedly grew an identical methicillin‐sensitive S. aureus determined by whole genome sequencing, and the patient received high dose intravenous flucloxacillin, ciprofloxacin and rifampicin (Box). Transoesophageal echocardiography confirmed vegetations on prosthetic aortic and native mitral valves, and the aortic root was thickened with possible paravalvular root abscess. Scheduled cardiopulmonary bypass for operative source control was postponed after a haemorrhagic infarction in the distribution of the left anterior cerebral artery on day −7 (ie, a week before starting bacteriophage therapy), despite concerns regarding development of an aortic root abscess, ongoing fevers and hypotension. Intravenous AB‐SA01 was administered twice a day for 14 days in conjunction with the patient's prescribed antibiotics, commencing (Day 1) 9 days after his first positive blood culture. Blood cultures were negative at onset of bacteriophage therapy, and the C‐reactive protein, temperature, and white cell count results showed downward trends within 24 hours (Box). This trajectory was only interrupted by splenic infarction and occlusion of the superior mesenteric artery 48 hours after commencement, which was proven on computed tomography scan (not shown). No fevers, tachycardia, hypotension or rashes were detected after bacteriophage infusions and no adverse sequelae were attributable to the therapy. The patient recovered after 40 days of antibiotic therapy and returned to his home state for follow‐up. A positron emission tomography scan on Day 80 showed no fluorodeoxyglucose‐avid lesions, including intracardiac lesions. Repeat echocardiogram on Day 98 for progressive heart failure showed severely dilated left ventricle with moderate mitral and trivial aortic regurgitation. A possible mechanical aortic valve vegetation and paravalvular phlegmon were again demonstrated. Blood cultures were negative. He declined surgical intervention and died on Day 103. To our knowledge, this was the first case of staphylococcal prosthetic valve endocarditis treated with intravenous bacteriophage (AB‐SA01), which complies with good manufacturing practice standards.4 Bacteriophage infusions were well tolerated. Future controlled trials are needed to evaluate adjunctive bacteriophage therapy, especially when surgical intervention is not feasible. Box – Graphical representation of antimicrobial treatment, bacteriophage therapy and inflammatory markers − = negative blood cultures; + = positive blood cultures; CRP = C‐reactive protein; SMA = superior mesenteric artery; WCC = white cell count. ◆

Timothy Gilbey · Josephine Ho · Louise A Cooley · Aleksandra Petrovic Fabijan · Jonathan R Iredell