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Papers by Rachel Herbert

Pediatric Infectious Disease Journal, 2020

Instructive Cases Background: To date, although neonatal infections with severe acute respiratory... more Instructive Cases Background: To date, although neonatal infections with severe acute respiratory syndrome coronovirus 2 (SARS-CoV-2) have been described, none of these have been proven to be the result of vertical transmission of SARS-CoV-2. Methods: We describe the probable vertical transmission of SARS-CoV-2 in a neonate born to a mother with coronavirus disease 2019 (COVID-19). Results: Following cesarean section, the neonate was kept in strict isolation. Molecular tests for SARS-CoV-2 on respiratory samples, blood, and meconium were initially negative, but positive on a nasopharyngeal aspirate on the third day of life. On day 5, the neonate developed fever and coryza, which spontaneously resolved. Viral genomic analysis from the mother and neonate showed identical sequences except for 1 nucleotide. Conclusion: This report has important implications for infection control and clinical management of pregnant women with COVID-19 and their newborns.

Anaesthesia & Intensive Care Medicine, 2018

The central nervous system (CNS) may be infected by a number of organisms including bacteria, vir... more The central nervous system (CNS) may be infected by a number of organisms including bacteria, viruses, fungi, and protozoa. Non-infectious causes such as autoimmune and vascular conditions may present with similar clinical syndromes necessitating the appropriate laboratory requests and good diagnostics. CNS infections are associated with significant morbidity and mortality, often requiring surgical intervention and admission to neurointensive care units. Common infection diagnoses seen in the neurointensive care unit include meningitis, ventriculitis, encephalitis and abscesses, including brain and spine. New and emerging pathogens in ITU settings include Candida auris and multiresistant Gram negative bacteria, which are easily transmissible and may threaten the antimicrobial choices available for patients.

Journal of Hospital Infection, 2019

Background: Certain Clostridium difficile ribotypes have been associated with complex disease phe... more Background: Certain Clostridium difficile ribotypes have been associated with complex disease phenotypes including recurrence and increased severity, especially the welldescribed hypervirulent RT027. This study aimed to determine the pattern of ribotypes causing infection and the association, if any, with severity. Methods: All faecal samples submitted to a large diagnostic laboratory for C. difficile testing between 2011 and 2013 were subject to routine testing and culture. All C. difficile isolates were ribotyped, and associated clinical and demographic patient data were retrieved and linked to ribotyping data. Results: In total, 86 distinct ribotypes were identified from 705 isolates of C. difficile. RT002 and RT015 were the most prevalent (22.5%, N¼159). Only five isolates (0.7%) were hypervirulent RT027. Ninety of 450 (20%) patients with clinical information available died within 30 days of C. difficile isolation. RT220, one of the 10 most common ribotypes, was associated with elevated median C-reactive protein and significantly increased 30-day allcause mortality compared with RT002 and RT015, and with all other ribotypes found in the study. Conclusions: A wide range of C. difficile ribotypes were responsible for C. difficile infection presentations. Although C. difficile-associated mortality has reduced in recent years, expansion of lineages associated with increased severity could herald increases in future mortality. Enhanced surveillance for emerging lineages such as RT220 that are associated with more severe disease is required, with genomic approaches to dissect pathogenicity.

BMJ, 2013

A 27 year old woman developed an inflamed pinna after an insect bite in Brazil. We provisionally ... more A 27 year old woman developed an inflamed pinna after an insect bite in Brazil. We provisionally diagnosed otitis externa with perichondritis. Wound swabs isolated yeasts and mixed coliforms. Her condition worsened despite microsuction and a month of topical and systemic antimicrobials. Rheumatology review excluded relapsing polychondritis. Subsequent skin biopsies identified Leishmania viannia parasites, a subgenus of new world cutaneous leishmaniasis (NWCL). A 20 day course of sodium stibogluconate (a pentavalent antimonial) improved her symptoms. NWCL in returning travellers should be considered, especially with the risk of mucocutaneous dissemination.

Nicotine & Tobacco Research, 2005

Clinical guidelines recommend that U.K. health professionals prescribe NRT in pregnancy. The pres... more Clinical guidelines recommend that U.K. health professionals prescribe NRT in pregnancy. The present study was conducted to determine (a) general practitioners' confidence in their ability to deliver a range of smoking cessation interventions, including NRT, in pregnancy, (b) the frequency with which general practitioners recall prescribing NRT in pregnancy, and (c) the factors that influence general practitioners to prescribe NRT in pregnancy. We conducted a mail survey of 368 general practitioners (family physicians) working in four districts of Nottingham, England (response rate = 68.6%). Some 27.1% of respondents recalled prescribing NRT to pregnant women (9.2% were unsure). General practitioners were less confident about their ability to prescribe NRT in pregnancy than they were of their ability to deliver other simple smoking cessation interventions in pregnancy. Most general practitioners (62%) believed NRT to be effective in pregnancy and safer than smoking (70%), but fewer (45%) believed NRT to be safe in pregnancy per se. Multiple logistic regression demonstrated that general practitioners who believed NRT use in pregnancy was safer than smoking were most likely to recall having prescribed it, OR = 4.94, 95% CI = 1.31-18.71. Many general practitioners were unsure about the safety of NRT in pregnancy, which may explain their relatively low confidence in their ability to prescribe NRT in pregnancy, compared with other interventions. The key factor influencing general practitioners' prescribing decisions was a belief that NRT use in pregnancy was likely to be safer than smoking. Empirical evidence about the safety and efficacy of NRT use in pregnancy is required to inform general practitioners' decisions about prescribing NRT to pregnant women who smoke.

Journal of Hospital Infection, 2013

Letter to the Editor Reply to Wiegand et al.: Proton pump inhibitor over-use and the ongoing batt... more Letter to the Editor Reply to Wiegand et al.: Proton pump inhibitor over-use and the ongoing battle to control Clostridium difficile infection in hospitals Madam, Wiegand et al. highlighted the vast economic and clinical burden of C. difficile infection (CDI) in their systematic review of CDI-related mortality, length of stay, recurrence and related cost. 1 Mortality rates ranged from 2% to 42%, with the highest mortality being found in the UK and the lowest in France. Length of stay was on average 14 days longer for patients with C. difficile infection in the UK. Research has identified proton pump inhibitor (PPI) use as a potential risk factor for CDI, although the exact relationship remains unclear. In 2006, Dial et al. found that exposure to a PPI was associated with an increased risk of communityacquired C. difficile-associated disease (odds ratio: 3.5; 95% confidence interval: 2.3e5.2). 2 In 2010, recurrent CDI was linked to PPI exposure, with a study showing 42% increased risk of CDI recurrence when PPI use was continued throughout treatment of infection. 3 Following this they recommended that PPI therapy should be stopped during CDI. Further research by Howell et al. identified a doseeresponse relationship between level of iatrogenic gastric acid suppression and nosocomial CDI rates. 4 The UK guidelines on the indication for PPIs advise to avoid long-term use of PPIs except in specific circumstances and to use 'step-down' low-dose acid suppression therapy if long courses are required. 5 We have conducted a point prevalence study of the number of patients on PPIs across three medical wards at West Middlesex University Hospital in West London. Seventy-seven patients were included, reviewing PPI drug, dose, indication for therapy, duration of use and concurrent antibiotic use. The results revealed a high volume of PPI prescriptions, particularly on the non-acute wards. Forty-one of 77 (53%) patients were on regular PPI therapy, and no indication was stated or apparent in the majority of these cases (24/41, 59%). The majority of patients had commenced PPI therapy prior to admission (76%, 31/41); it was not possible to ascertain whether this was in primary or secondary care. Twenty-six percent of patients had been prescribed antibiotics concurrently during their admission.

HIV Medicine, 2012

Early diagnosis of HIV infection reduces morbidity and mortality associated with late presentatio... more Early diagnosis of HIV infection reduces morbidity and mortality associated with late presentation. Despite UK guidelines, the HIV testing rate has not increased. We have introduced universal HIV screening in an open-access returning traveller clinic. Data were prospectively recorded for all patients attending the open-access returning traveller clinic between August 2008 and December 2010. HIV testing was offered to all patients from May 2009; initially testing with laboratory samples (phase 1) and subsequently a point-of-care test (POCT) (phase 2). A total of 4965 patients attended the clinic; 1342 in phase 0, 792 in phase 1 and 2831 in phase 2. Testing rates for HIV increased significantly from 2% (38 of 1342) in phase 0 to 23.1% (183 of 792) in phase 1 and further increased to 44.5% (1261 of 2831) during phase 2 (P < 0.0001). Two new diagnoses of HIV-1 were identified in phase 1 (1.1% of tested); seven patients had a reactive POCT test in phase 2, of whom five (0.4% of those tested) were confirmed in a 4th generation assay. The patients with false reactive tests had a concurrent Plasmodium falciparum infection. Patients travelling to the Middle East and Europe were less likely to accept an HIV test with POCT. A nurse-delivered universal point-of-care HIV testing service has been successfully introduced and sustained in an acute medical clinic in a low-prevalence country. Caution is required in communicating reactive results in low-prevalence settings where there may be alternative diagnoses or a low population prevalence of HIV infection.

BMJ Case Reports, 2020

Yersinia pseudotuberculosis is a Gram-negative zoonosis which occasionally infects humans via ing... more Yersinia pseudotuberculosis is a Gram-negative zoonosis which occasionally infects humans via ingestion of contaminated food and water, and typically causes a self-limiting gastrointestinal tract infection. Patients who are immunocompromised, have haemochromatosis or liver cirrhosis are more likely to develop serious complications such as bacteraemia. We present the case of a 76-year-old man with fever and an acutely tender, swollen right knee. Blood cultures were positive for Y. pseudotuberculosis, and 16s ribosomal PCR analysis of his knee aspirate confirmed septic arthritis. He was treated with intravenous ceftriaxone and made an excellent recovery following knee washout. Interestingly, our patient did not have any of the classic risk factors described in the literature, or history of exposure to the pathogen to explain his diagnosis. To our knowledge, this is only the second confirmed case of Y. pseudotuberculosis bacteraemia with septic arthritis, and the first to involve the k...

Medical Mycology Case Reports, 2021

Pediatric Infectious Disease Journal, 2020

Instructive Cases Background: To date, although neonatal infections with severe acute respiratory... more Instructive Cases Background: To date, although neonatal infections with severe acute respiratory syndrome coronovirus 2 (SARS-CoV-2) have been described, none of these have been proven to be the result of vertical transmission of SARS-CoV-2. Methods: We describe the probable vertical transmission of SARS-CoV-2 in a neonate born to a mother with coronavirus disease 2019 (COVID-19). Results: Following cesarean section, the neonate was kept in strict isolation. Molecular tests for SARS-CoV-2 on respiratory samples, blood, and meconium were initially negative, but positive on a nasopharyngeal aspirate on the third day of life. On day 5, the neonate developed fever and coryza, which spontaneously resolved. Viral genomic analysis from the mother and neonate showed identical sequences except for 1 nucleotide. Conclusion: This report has important implications for infection control and clinical management of pregnant women with COVID-19 and their newborns.

Anaesthesia & Intensive Care Medicine, 2018

The central nervous system (CNS) may be infected by a number of organisms including bacteria, vir... more The central nervous system (CNS) may be infected by a number of organisms including bacteria, viruses, fungi, and protozoa. Non-infectious causes such as autoimmune and vascular conditions may present with similar clinical syndromes necessitating the appropriate laboratory requests and good diagnostics. CNS infections are associated with significant morbidity and mortality, often requiring surgical intervention and admission to neurointensive care units. Common infection diagnoses seen in the neurointensive care unit include meningitis, ventriculitis, encephalitis and abscesses, including brain and spine. New and emerging pathogens in ITU settings include Candida auris and multiresistant Gram negative bacteria, which are easily transmissible and may threaten the antimicrobial choices available for patients.

Journal of Hospital Infection, 2019

Background: Certain Clostridium difficile ribotypes have been associated with complex disease phe... more Background: Certain Clostridium difficile ribotypes have been associated with complex disease phenotypes including recurrence and increased severity, especially the welldescribed hypervirulent RT027. This study aimed to determine the pattern of ribotypes causing infection and the association, if any, with severity. Methods: All faecal samples submitted to a large diagnostic laboratory for C. difficile testing between 2011 and 2013 were subject to routine testing and culture. All C. difficile isolates were ribotyped, and associated clinical and demographic patient data were retrieved and linked to ribotyping data. Results: In total, 86 distinct ribotypes were identified from 705 isolates of C. difficile. RT002 and RT015 were the most prevalent (22.5%, N¼159). Only five isolates (0.7%) were hypervirulent RT027. Ninety of 450 (20%) patients with clinical information available died within 30 days of C. difficile isolation. RT220, one of the 10 most common ribotypes, was associated with elevated median C-reactive protein and significantly increased 30-day allcause mortality compared with RT002 and RT015, and with all other ribotypes found in the study. Conclusions: A wide range of C. difficile ribotypes were responsible for C. difficile infection presentations. Although C. difficile-associated mortality has reduced in recent years, expansion of lineages associated with increased severity could herald increases in future mortality. Enhanced surveillance for emerging lineages such as RT220 that are associated with more severe disease is required, with genomic approaches to dissect pathogenicity.

BMJ, 2013

A 27 year old woman developed an inflamed pinna after an insect bite in Brazil. We provisionally ... more A 27 year old woman developed an inflamed pinna after an insect bite in Brazil. We provisionally diagnosed otitis externa with perichondritis. Wound swabs isolated yeasts and mixed coliforms. Her condition worsened despite microsuction and a month of topical and systemic antimicrobials. Rheumatology review excluded relapsing polychondritis. Subsequent skin biopsies identified Leishmania viannia parasites, a subgenus of new world cutaneous leishmaniasis (NWCL). A 20 day course of sodium stibogluconate (a pentavalent antimonial) improved her symptoms. NWCL in returning travellers should be considered, especially with the risk of mucocutaneous dissemination.

Nicotine & Tobacco Research, 2005

Clinical guidelines recommend that U.K. health professionals prescribe NRT in pregnancy. The pres... more Clinical guidelines recommend that U.K. health professionals prescribe NRT in pregnancy. The present study was conducted to determine (a) general practitioners' confidence in their ability to deliver a range of smoking cessation interventions, including NRT, in pregnancy, (b) the frequency with which general practitioners recall prescribing NRT in pregnancy, and (c) the factors that influence general practitioners to prescribe NRT in pregnancy. We conducted a mail survey of 368 general practitioners (family physicians) working in four districts of Nottingham, England (response rate = 68.6%). Some 27.1% of respondents recalled prescribing NRT to pregnant women (9.2% were unsure). General practitioners were less confident about their ability to prescribe NRT in pregnancy than they were of their ability to deliver other simple smoking cessation interventions in pregnancy. Most general practitioners (62%) believed NRT to be effective in pregnancy and safer than smoking (70%), but fewer (45%) believed NRT to be safe in pregnancy per se. Multiple logistic regression demonstrated that general practitioners who believed NRT use in pregnancy was safer than smoking were most likely to recall having prescribed it, OR = 4.94, 95% CI = 1.31-18.71. Many general practitioners were unsure about the safety of NRT in pregnancy, which may explain their relatively low confidence in their ability to prescribe NRT in pregnancy, compared with other interventions. The key factor influencing general practitioners' prescribing decisions was a belief that NRT use in pregnancy was likely to be safer than smoking. Empirical evidence about the safety and efficacy of NRT use in pregnancy is required to inform general practitioners' decisions about prescribing NRT to pregnant women who smoke.

Journal of Hospital Infection, 2013

Letter to the Editor Reply to Wiegand et al.: Proton pump inhibitor over-use and the ongoing batt... more Letter to the Editor Reply to Wiegand et al.: Proton pump inhibitor over-use and the ongoing battle to control Clostridium difficile infection in hospitals Madam, Wiegand et al. highlighted the vast economic and clinical burden of C. difficile infection (CDI) in their systematic review of CDI-related mortality, length of stay, recurrence and related cost. 1 Mortality rates ranged from 2% to 42%, with the highest mortality being found in the UK and the lowest in France. Length of stay was on average 14 days longer for patients with C. difficile infection in the UK. Research has identified proton pump inhibitor (PPI) use as a potential risk factor for CDI, although the exact relationship remains unclear. In 2006, Dial et al. found that exposure to a PPI was associated with an increased risk of communityacquired C. difficile-associated disease (odds ratio: 3.5; 95% confidence interval: 2.3e5.2). 2 In 2010, recurrent CDI was linked to PPI exposure, with a study showing 42% increased risk of CDI recurrence when PPI use was continued throughout treatment of infection. 3 Following this they recommended that PPI therapy should be stopped during CDI. Further research by Howell et al. identified a doseeresponse relationship between level of iatrogenic gastric acid suppression and nosocomial CDI rates. 4 The UK guidelines on the indication for PPIs advise to avoid long-term use of PPIs except in specific circumstances and to use 'step-down' low-dose acid suppression therapy if long courses are required. 5 We have conducted a point prevalence study of the number of patients on PPIs across three medical wards at West Middlesex University Hospital in West London. Seventy-seven patients were included, reviewing PPI drug, dose, indication for therapy, duration of use and concurrent antibiotic use. The results revealed a high volume of PPI prescriptions, particularly on the non-acute wards. Forty-one of 77 (53%) patients were on regular PPI therapy, and no indication was stated or apparent in the majority of these cases (24/41, 59%). The majority of patients had commenced PPI therapy prior to admission (76%, 31/41); it was not possible to ascertain whether this was in primary or secondary care. Twenty-six percent of patients had been prescribed antibiotics concurrently during their admission.

HIV Medicine, 2012

Early diagnosis of HIV infection reduces morbidity and mortality associated with late presentatio... more Early diagnosis of HIV infection reduces morbidity and mortality associated with late presentation. Despite UK guidelines, the HIV testing rate has not increased. We have introduced universal HIV screening in an open-access returning traveller clinic. Data were prospectively recorded for all patients attending the open-access returning traveller clinic between August 2008 and December 2010. HIV testing was offered to all patients from May 2009; initially testing with laboratory samples (phase 1) and subsequently a point-of-care test (POCT) (phase 2). A total of 4965 patients attended the clinic; 1342 in phase 0, 792 in phase 1 and 2831 in phase 2. Testing rates for HIV increased significantly from 2% (38 of 1342) in phase 0 to 23.1% (183 of 792) in phase 1 and further increased to 44.5% (1261 of 2831) during phase 2 (P < 0.0001). Two new diagnoses of HIV-1 were identified in phase 1 (1.1% of tested); seven patients had a reactive POCT test in phase 2, of whom five (0.4% of those tested) were confirmed in a 4th generation assay. The patients with false reactive tests had a concurrent Plasmodium falciparum infection. Patients travelling to the Middle East and Europe were less likely to accept an HIV test with POCT. A nurse-delivered universal point-of-care HIV testing service has been successfully introduced and sustained in an acute medical clinic in a low-prevalence country. Caution is required in communicating reactive results in low-prevalence settings where there may be alternative diagnoses or a low population prevalence of HIV infection.

BMJ Case Reports, 2020

Yersinia pseudotuberculosis is a Gram-negative zoonosis which occasionally infects humans via ing... more Yersinia pseudotuberculosis is a Gram-negative zoonosis which occasionally infects humans via ingestion of contaminated food and water, and typically causes a self-limiting gastrointestinal tract infection. Patients who are immunocompromised, have haemochromatosis or liver cirrhosis are more likely to develop serious complications such as bacteraemia. We present the case of a 76-year-old man with fever and an acutely tender, swollen right knee. Blood cultures were positive for Y. pseudotuberculosis, and 16s ribosomal PCR analysis of his knee aspirate confirmed septic arthritis. He was treated with intravenous ceftriaxone and made an excellent recovery following knee washout. Interestingly, our patient did not have any of the classic risk factors described in the literature, or history of exposure to the pathogen to explain his diagnosis. To our knowledge, this is only the second confirmed case of Y. pseudotuberculosis bacteraemia with septic arthritis, and the first to involve the k...

Medical Mycology Case Reports, 2021