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Wilson E, Dimitriou A, Munnings A, Hunt A. Use of the Microguide mobile phone application for ENT conditions: a national review. J Laryngol Otol 2024; 138:242-245. [PMID: 37435801 DOI: 10.1017/s0022215123001263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2023]
Abstract
OBJECTIVE Smartphone applications are used widely in healthcare, including antimicrobial applications such as Microguide. There has been no review of hospitals using this smartphone application for ENT conditions. METHODS This study analysed all hospital accounts using Microguide and examined the ENT conditions that were listed. RESULTS In total, 123 hospitals were included in this study; 45 ENT-related conditions were listed on Microguide across all hospitals, with an average of 8 conditions listed per hospital. CONCLUSION There is a significant disparity of ENT conditions listed on Microguide. A suggested list is recommended to be included for ENT departments using Microguide, to help improve antimicrobial stewardship for the specialty.
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Affiliation(s)
- Emily Wilson
- Department of ENT, Milton Keynes University Hospital, Milton Keynes, UK
| | - Alexia Dimitriou
- Department of ENT, Milton Keynes University Hospital, Milton Keynes, UK
| | - Amberley Munnings
- Department of ENT, Milton Keynes University Hospital, Milton Keynes, UK
| | - Alison Hunt
- Department of ENT, Milton Keynes University Hospital, Milton Keynes, UK
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2
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Turner R, Hart J, Ashiru-Oredope D, Atkins L, Eades C, Felton T, Howlett E, Rice S, Shallcross L, Lorencatto F, Byrne-Davis L. A qualitative interview study applying the COM-B model to explore how hospital-based trainers implement antimicrobial stewardship education and training in UK hospital-based care. BMC Health Serv Res 2023; 23:770. [PMID: 37468860 DOI: 10.1186/s12913-023-09559-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 05/16/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND Antimicrobial resistance (AMR) is a major global health threat caused by the inappropriate use of antimicrobials in healthcare and other settings. Antimicrobial stewardship (AMS) is a broad multi-component health services intervention that promotes and monitors the judicious use of antimicrobials to preserve their future effectiveness. A main component of AMS is education and training (E&T). However, there are often discrepancies in how such interventions are implemented and delivered in hospital-based care. The aim of this study was to explore the factors influencing the implementation of AMS E&T in UK hospitals. METHODS Semi-structured interviews were carried out with AMS E&T trainers in UK hospitals. The interview schedule was developed using the Capability, Opportunity, Motivation = Behaviour (COM-B) model. Participants were identified via professional networks and social media. Interviews were analysed using inductive thematic analysis, followed by deductive analysis using the COM-B model as a framework. RESULTS A total of 34 participants (26 antimicrobial pharmacists, 3 nurses, 1 advanced clinical practitioner, 2 infectious disease consultants, 1 microbiologist and 1 clinical scientist). responsible for designing, implementing and evaluating AMS E&T in UK hospitals (five from Northern Ireland, four from Wales, two from Scotland and 23 from England) took part in virtual interviews. Key themes were: (1) The organisational context, including system-level barriers to AMS included competing organisational targets (Reflective motivation and physical opportunity) and the impact of the COVID-19 pandemic on activity (Physical opportunity); (2) Healthcare professionals' roles and the wider multi-disciplinary team, such that AMS roles were defined and addressed poorly in E&T (Social opportunity); and (3) The individual perception of the need for AMS E&T in hospital-based care, manifest in a perceived lack of conviction of the wider threat of AMR and the resulting need for AMS E&T (Reflective motivation). CONCLUSION This study has identified factors influencing implementation of AMS E&T in UK hospitals and further identified where implemented, AMS E&T did not address real-world challenges. Current AMS E&T needs to be optimised to elicit practice change, with recommendations including training and engaging the wider work-force and drawing upon theoretically-informed intervention development frameworks to inform AMS E&T to better target AMS behaviour change.
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Affiliation(s)
- Rebecca Turner
- Division of Psychology and Mental Health, Faculty of Biology, Medicine & Health, the University of Manchester, Manchester, UK.
| | - Jo Hart
- Division of Medical Education, Faculty of Biology, Medicine & Health, the University of Manchester, Manchester, UK
| | | | - Lou Atkins
- Centre for Behaviour Change, University College London, London, UK
| | - Christopher Eades
- Department of Infectious Diseases, Manchester University NHS Foundation Trust, Manchester, UK
| | - Tim Felton
- Department of Critical Care Medicine, Wythenshawe Hospital, Manchester University NHS Foundation, Manchester, UK
| | - Emily Howlett
- Vocal, Manchester University NHS Foundation Trust, Manchester, UK
| | - Stephen Rice
- Population Health Sciences Institute, Faculty of Medical Sciences, the University of Newcastle Upon, Tyne, UK
| | - Laura Shallcross
- Institute of Health Informatics, University College London, London, UK
| | | | - Lucie Byrne-Davis
- Division of Medical Education, Faculty of Biology, Medicine & Health, the University of Manchester, Manchester, UK
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3
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Molina J, Rosso-Fernández CM, Montero-Mateos E, Paño-Pardo JR, Solla M, Guisado-Gil AB, Álvarez-Marín R, Pachón-Ibáñez ME, Gimeno A, Martín-Gutiérrez G, Lepe JA, Cisneros JM. Study protocol for a randomized clinical trial to assess 7 versus 14-days of treatment for Pseudomonas aeruginosa bloodstream infections (SHORTEN-2 trial). PLoS One 2022; 17:e0277333. [PMID: 36548225 PMCID: PMC9778939 DOI: 10.1371/journal.pone.0277333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 10/24/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Research priorities in Antimicrobial Stewardship (AMS) have rapidly evolved in the last decade. The need for a more efficient use of antimicrobials have fueled plenty of studies to define the optimal duration for antibiotic treatments, and yet, there still are large areas of uncertainty in common clinical scenarios. Pseudomonas aeruginosa has been pointed as a priority for clinical research, but it has been unattended by most randomized trials tackling the effectiveness of short treatments. The study protocol of the SHORTEN-2 trial is presented as a practical example of new ways to approach common obstacles for clinical research in AMS. OBJECTIVE To determine whether a 7-day course of antibiotics is superior to 14-day schemes for treating bloodstream infections by P. aeruginosa (BSI-PA). METHODS A superiority, open-label, randomized controlled trial will be performed across 30 Spanish hospitals. Adult patients with uncomplicated BSI-PA will be randomized to receive a 7 versus 14-day course of any active antibiotic. The primary endpoint will be the probability for the 7-day group of achieving better outcomes than the control group, assessing altogether clinical effectiveness, severe adverse events, and antibiotic exposure through a DOOR/RADAR analysis. Main secondary endpoints include treatment failure, BSI-PA relapses, and mortality. A superiority design was set for the primary endpoint and non-inferiority for treatment failure, resulting in a sample size of 304 patients. CONCLUSIONS SHORTEN-2 trial aligns with some of the priorities for clinical research in AMS. The implementation of several methodological innovations allowed overcoming common obstacles, like feasible sample sizes or measuring the clinical impact and unintended effects. TRIAL REGISTRATION EudraCt: 2021-003847-10; ClinicalTrials.gov: NCT05210439.
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Affiliation(s)
- José Molina
- Unit of Infectious Diseases, Microbiology and Parasitology, Virgen del Rocío University Hospital, Seville, Spain
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital/CSIC/University of Seville, Seville, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | | | - Enrique Montero-Mateos
- Department of Pathology and Institute of Biomedical Research of Salamanca (IBSAL), University Hospital of Salamanca, Salamanca, Spain
| | - José Ramón Paño-Pardo
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
- Department of Infectious Diseases, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
- Instituto de Investigación Sanitaria Aragón (IIS Aragón), Zaragoza, Spain
| | - María Solla
- Unit of Infectious Diseases, Microbiology and Parasitology, Virgen del Rocío University Hospital, Seville, Spain
- Unidad de Investigación Clínica y Ensayos Clínicos (CTU), Hospital Virgen del Rocío, Sevilla, Spain
| | - Ana Belén Guisado-Gil
- Unit of Infectious Diseases, Microbiology and Parasitology, Virgen del Rocío University Hospital, Seville, Spain
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital/CSIC/University of Seville, Seville, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
- Department of Pharmacy, Virgen del Rocío University Hospital, Seville, Spain
| | - Rocío Álvarez-Marín
- Unit of Infectious Diseases, Microbiology and Parasitology, Virgen del Rocío University Hospital, Seville, Spain
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital/CSIC/University of Seville, Seville, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - María Eugenia Pachón-Ibáñez
- Unit of Infectious Diseases, Microbiology and Parasitology, Virgen del Rocío University Hospital, Seville, Spain
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital/CSIC/University of Seville, Seville, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - Adelina Gimeno
- Unit of Infectious Diseases, Microbiology and Parasitology, Virgen del Rocío University Hospital, Seville, Spain
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital/CSIC/University of Seville, Seville, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - Guillermo Martín-Gutiérrez
- Unit of Infectious Diseases, Microbiology and Parasitology, Virgen del Rocío University Hospital, Seville, Spain
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital/CSIC/University of Seville, Seville, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - José Antonio Lepe
- Unit of Infectious Diseases, Microbiology and Parasitology, Virgen del Rocío University Hospital, Seville, Spain
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital/CSIC/University of Seville, Seville, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - José Miguel Cisneros
- Unit of Infectious Diseases, Microbiology and Parasitology, Virgen del Rocío University Hospital, Seville, Spain
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital/CSIC/University of Seville, Seville, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
- * E-mail:
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4
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Budgell EP, Davies TJ, Donker T, Hopkins S, Wyllie DH, Peto TEA, Gill MJ, Llewelyn MJ, Walker AS. Impact of hospital antibiotic use on patient-level risk of death among 36,124,372 acute and medical admissions in England. J Infect 2021; 84:311-320. [PMID: 34963640 DOI: 10.1016/j.jinf.2021.12.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 12/03/2021] [Accepted: 12/17/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Initiatives to curb hospital antibiotic use might be associated with harm from under-treatment. We examined the extent to which variation in hospital antibiotic prescribing is associated with mortality risk in acute/general medicine inpatients. METHODS This ecological analysis examined Hospital Episode Statistics from 36,124,372 acute/general medicine admissions (≥16y) to 135 acute hospitals in England, 01/April/2010-31/March/2017. Random-effects meta-regression was used to investigate whether heterogeneity in adjusted 30-day mortality was associated with hospital-level antibiotic use, measured in defined-daily-doses (DDD)/1,000 bed-days. Models also considered DDDs/1,000 admissions and DDDs for narrow-spectrum/broad-spectrum antibiotics, parenteral/oral, and local interpretations of World Health Organization Access, Watch, and Reserve antibiotics. RESULTS Hospital-level antibiotic DDDs/1,000 bed-days varied 15-fold with comparable variation in broad-spectrum, parenteral, and Reserve antibiotic use. After extensive adjusting for hospital case-mix, the probability of 30-day mortality changed -0.010% (95% CI: -0.064,+0.044) for each increase of 500 hospital-level antibiotic DDDs/1,000 bed-days. Analyses of other metrics of antibiotic use showed no consistent association with mortality risk. CONCLUSIONS We found no evidence that wide variation in hospital antibiotic use is associated with adjusted mortality risk in acute/general medicine inpatients. Using low-prescribing hospitals as benchmarks could help drive safe and substantial reductions in antibiotic consumption of up-to one-third in this population.
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Affiliation(s)
- Eric P Budgell
- Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Timothy J Davies
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Tjibbe Donker
- Institute for Infection Prevention and Hospital Epidemiology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Susan Hopkins
- National Infection Service, Public Health England, UK
| | | | - Tim E A Peto
- Nuffield Department of Medicine, University of Oxford, Oxford, UK; NIHR Biomedical Research Centre, Oxford, UK; National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Oxford, UK
| | - Martin J Gill
- Clinical Microbiology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Martin J Llewelyn
- Global Health and Infectious Diseases, Brighton and Sussex Medical School, University of Sussex, Brighton, UK; Department of Microbiology and Infection, Royal Sussex County Hospital, Brighton, UK
| | - A Sarah Walker
- Nuffield Department of Medicine, University of Oxford, Oxford, UK; NIHR Biomedical Research Centre, Oxford, UK; National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Oxford, UK
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5
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Hand KS, Clancy B, Allen M, Mayes A, Patel Y, Latter SM. 'It makes life so much easier'-experiences of users of the MicroGuide™ smartphone app for improving antibiotic prescribing behaviour in UK hospitals: an interview study. JAC Antimicrob Resist 2021; 3:dlab111. [PMID: 34632385 PMCID: PMC8496772 DOI: 10.1093/jacamr/dlab111] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 06/17/2021] [Indexed: 11/12/2022] Open
Abstract
Objectives To understand the impact on prescribing behaviour of an antimicrobial therapy
guidelines smartphone app, in widespread use in hospitals in the UK. Methods Twenty-eight doctors and five nurse prescribers from four purposively
selected hospitals in the UK participated in behavioural theory-informed
semi-structured interviews about their experiences of using the
MicroGuide™ smartphone app. Data were analysed using a thematic
content analysis. Results Five themes emerged from the interview data: convenience and accessibility;
validation of prescribing decisions; trust in app content; promotion of
antimicrobial stewardship; and limitations and concerns. Participants
appreciated the perceived convenience, accessibility and timesaving
attributes of the app, potentially contributing to more prompt treatment of
patients with time-critical illness. The interviewees also reported finding
it reassuring to use the app to support decision-making and to validate
existing knowledge. They trusted the app content authored by local experts
and considered it to be evidence-based and up-to-date. This was believed to
result in fewer telephone calls to the microbiology department for advice.
Participants recognized the value of the app for supporting the goals of
antimicrobial stewardship by promoting the responsible and proportionate use
of antimicrobials. Finally, a number of limitations of the app were
reported, including the risk of de-skilling trainees, cultural problems with
using smartphones in clinical environments and software technical
problems. Conclusions The MicroGuide app was valued as a means of addressing an unmet need for
updated, concise, trustworthy specialist information in an accessible format
at the bedside to support safe and effective antimicrobial prescribing.
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Affiliation(s)
- Kieran S Hand
- Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Bridget Clancy
- Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Mike Allen
- Merck Sharp & Dohme Limited, Hertford Road, Hoddesdon, UK
| | - Amazigom Mayes
- Merck Sharp & Dohme Limited, Hertford Road, Hoddesdon, UK
| | - Yash Patel
- Merck Sharp & Dohme Limited, Hertford Road, Hoddesdon, UK
| | - Susan M Latter
- Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
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6
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Hamill LM, Bonnett J, Baxter MF, Kreutz M, Denny KJ, Keijzers G. Antimicrobial Prescribing in the Emergency Department; Who Is Calling the Shots? Antibiotics (Basel) 2021; 10:antibiotics10070843. [PMID: 34356764 PMCID: PMC8300735 DOI: 10.3390/antibiotics10070843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/05/2021] [Accepted: 07/08/2021] [Indexed: 11/16/2022] Open
Abstract
Objective: Inappropriate antimicrobial prescribing in the emergency department (ED) can lead to poor outcomes. It is unknown how often the prescribing clinician is guided by others, and whether prescriber factors affect appropriateness of prescribing. This study aims to describe decision making, confidence in, and appropriateness of antimicrobial prescribing in the ED. Methods: Descriptive study in two Australian EDs using both questionnaire and medical record review. Participants were clinicians who prescribed antimicrobials to patients in the ED. Outcomes of interest were level of decision-making (self or directed), confidence in indication for prescribing and appropriateness (5-point Likert scale, 5 most confident). Appropriateness assessment of the prescribing event was by blinded review using the National Antibiotic Prescribing Survey appropriateness assessment tool. All analyses were descriptive. Results: Data on 88 prescribers were included, with 61% making prescribing decisions themselves. The 39% directed by other clinicians were primarily guided by more senior ED and surgical subspecialty clinicians. Confidence that antibiotics were indicated (Likert score: 4.20, 4.35 and 4.35) and appropriate (Likert score: 4.07, 4.23 and 4.29) was similar for juniors, mid-level and senior prescribers, respectively. Eighty-five percent of prescriptions were assessed as appropriate, with no differences in appropriateness by seniority, decision-making or confidence. Conclusions: Over one-third of prescribing was guided by senior ED clinicians or based on specialty advice, primarily surgical specialties. Prescriber confidence was high regardless of seniority or decision-maker. Overall appropriateness of prescribing was good, but with room for improvement. Future qualitative research may provide further insight into the intricacies of prescribing decision-making.
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Affiliation(s)
- Laura M. Hamill
- Department of Emergency Medicine, Christchurch Hospital, Canterbury DHB, Christchurch 8011, New Zealand;
| | - Julia Bonnett
- School of Medicine, Griffith University, Gold Coast, QLD 4215, Australia; (J.B.); (M.F.B.); (M.K.)
| | - Megan F. Baxter
- School of Medicine, Griffith University, Gold Coast, QLD 4215, Australia; (J.B.); (M.F.B.); (M.K.)
| | - Melina Kreutz
- School of Medicine, Griffith University, Gold Coast, QLD 4215, Australia; (J.B.); (M.F.B.); (M.K.)
| | - Kerina J. Denny
- Department of Intensive Care, Gold Coast University Hospital, Gold Coast, QLD 4215, Australia;
| | - Gerben Keijzers
- School of Medicine, Griffith University, Gold Coast, QLD 4215, Australia; (J.B.); (M.F.B.); (M.K.)
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, QLD 4215, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD 4215, Australia
- Correspondence:
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7
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Mowbray F, Sivyer K, Santillo M, Jones N, Peto TEA, Walker AS, Llewelyn MJ, Yardley L. Patient engagement with antibiotic messaging in secondary care: a qualitative feasibility study of the ‘review and revise’ experience. Pilot Feasibility Stud 2020; 6:43. [PMID: 32280483 PMCID: PMC7126355 DOI: 10.1186/s40814-020-00590-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 03/24/2020] [Indexed: 01/22/2023] Open
Abstract
Abstract
Background
We aimed to investigate and optimise the acceptability and usefulness of a patient leaflet about antibiotic prescribing decisions made during hospitalisation, and to explore individual patient experiences and preferences regarding the process of antibiotic prescription ‘review and revise’ which is a key strategy to minimise antibiotic overuse in hospitals.
Methods
In this qualitative study, run within the feasibility study of a large, cluster-randomised stepped wedge trial of 36 hospital organisations, a series of semi-structured, think-aloud telephone interviews were conducted and data were analysed using thematic analysis. Fifteen adult patients who had experienced a recent acute medical hospital admission during which they had been prescribed antimicrobials and offered a patient leaflet about antibiotic prescribing were recruited to the study.
Results
Participants reacted positively to the leaflet, reporting that it was both an accessible and important source of information which struck the appropriate balance between informing and reassuring. Participants all valued open communication with clinicians, and were keen to be involved in antibiotic prescribing decisions, with individuals reporting positive experiences regarding antibiotic prescription changes or stopping. Many participants had prior experience or knowledge of antibiotics and resistance, and generally welcomed efforts to reduce antibiotic usage. Overall, there was a feeling that healthcare professionals (HCPs) are trusted experts providing the most appropriate treatment for individual patient conditions.
Conclusions
This study offers novel insights into how patients within secondary care are likely to respond to messages advocating a reduction in the use of antibiotics through the ‘review and revise’ approach. Due to the level of trust that patients place in their care provider, encouraging HCPs within secondary care to engage patients with greater communication and information provision could provide great advantages in the drive to reduce antibiotic use. It may also be beneficial for HCPs to view patient experiences as cumulative events that have the potential to impact future behaviour around antibiotic use. Finally, pre-testing messages about antibiotic prescribing and resistance is vital to dispelling any misconceptions either around effectiveness of treatment for patients, or perceptions of how messages may be received.
Trial registration
Current Controlled Trials ISRCTN12674243 (10 April 2017),
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8
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Shaw L. Representing antibiotic relationships using measurements of efficacy against clinical isolates. Wellcome Open Res 2020; 4:86. [PMID: 32995554 PMCID: PMC7520714 DOI: 10.12688/wellcomeopenres.15304.3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2020] [Indexed: 11/20/2022] Open
Abstract
Introduction. Antimicrobial resistance (AMR) is a worrying and confusing problem for both patients and medical professionals. It is often difficult for non-specialists to understand how different antibiotics are related to one another. Here, I use experimental data from hundreds of thousands of clinical isolates to infer relationships between antibiotics and represent them with simple diagrams. Methods. The minimum inhibitory concentration (MIC) of a bacterial isolate for a given antibiotic is defined as the lowest concentration that prevents visible growth. Measuring MICs for multiple antibiotics using the same isolate implicitly records the relationships of the antibiotics for a given species. The basic principle is that antibiotics with similar mechanisms of action should give rise to similar mechanisms of resistance, so should have correlated MICs across large numbers of isolates. This information can then be used to calculate distances between antibiotics based on pairwise correlations of their rank-ordered MICs. I apply this approach to a large historical AMR surveillance dataset (the Pfizer ATLAS surveillance dataset, 2004-2017). Results. I demonstrate that clustering antibiotics in this way allows a simple visual comparison of how similar antibiotics are to each other based on their efficacy within a species. The resulting visualizations broadly recapitulate antibiotic classes. They also clearly show the dramatic effects of combining beta-lactam antibiotics with beta-lactamase inhibitors, as well as highlighting antibiotics which have unexpected correlations in MICs that are not predicted from their chemical similarities alone. Conclusion. Large AMR surveillance datasets can be used in a hypothesis-free manner to show relationships between antibiotics based on their real-world efficacy.
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Affiliation(s)
- Liam Shaw
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
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9
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Santillo M, Sivyer K, Krusche A, Mowbray F, Jones N, Peto TEA, Walker AS, Llewelyn MJ, Yardley L. Intervention planning for Antibiotic Review Kit (ARK): a digital and behavioural intervention to safely review and reduce antibiotic prescriptions in acute and general medicine. J Antimicrob Chemother 2020; 74:3362-3370. [PMID: 31430366 PMCID: PMC6798845 DOI: 10.1093/jac/dkz333] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 05/07/2019] [Accepted: 07/07/2019] [Indexed: 12/11/2022] Open
Abstract
Background Hospital antimicrobial stewardship strategies, such as ‘Start Smart, Then Focus’ in the UK, balance the need for prompt, effective antibiotic treatment with the need to limit antibiotic overuse using ‘review and revise’. However, only a minority of review decisions are to stop antibiotics. Research suggests that this is due to both behavioural and organizational factors. Objectives To develop and optimize the Antibiotic Review Kit (ARK) intervention. ARK is a complex digital, organizational and behavioural intervention that supports implementation of ‘review and revise’ to help healthcare professionals safely stop unnecessary antibiotics. Methods A theory-, evidence- and person-based approach was used to develop and optimize ARK and its implementation. This was done through iterative stakeholder consultation and in-depth qualitative research with doctors, nurses and pharmacists in UK hospitals. Barriers to and facilitators of the intervention and its implementation, and ways to address them, were identified and then used to inform the intervention’s development. Results A key barrier to stopping antibiotics was reportedly a lack of information about the original prescriber’s rationale for and their degree of certainty about the need for antibiotics. An integral component of ARK was the development and optimization of a Decision Aid and its implementation to increase transparency around initial prescribing decisions. Conclusions The key output of this research is a digital and behavioural intervention targeting important barriers to stopping antibiotics at review (see http://bsac-vle.com/ark-the-antibiotic-review-kit/ and http://antibioticreviewkit.org.uk/). ARK will be evaluated in a feasibility study and, if successful, a stepped-wedge cluster-randomized controlled trial at acute hospitals across the NHS.
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Affiliation(s)
- M Santillo
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - K Sivyer
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - A Krusche
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - F Mowbray
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - N Jones
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - T E A Peto
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Nuffield Department of Medicine, University of Oxford, Oxford, UK.,NIHR Biomedical Centre, Oxford, UK
| | - A S Walker
- Nuffield Department of Medicine, University of Oxford, Oxford, UK.,NIHR Biomedical Centre, Oxford, UK
| | - M J Llewelyn
- Brighton and Sussex Medical School, University of Sussex, Falmer, UK
| | - L Yardley
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK.,School of Psychological Science, University of Bristol, Bristol, UK
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10
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Scobie A, Budd EL, Harris RJ, Hopkins S, Shetty N. Antimicrobial stewardship: an evaluation of structure and process and their association with antimicrobial prescribing in NHS hospitals in England. J Antimicrob Chemother 2020; 74:1143-1152. [PMID: 30649321 DOI: 10.1093/jac/dky538] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 10/30/2018] [Accepted: 11/26/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Rigorous antimicrobial stewardship programmes (ASPs) are an essential strategy against antimicrobial resistance. OBJECTIVES To evaluate and score ASPs in acute English NHS hospitals and determine association of ASP scores with antimicrobial prescribing. METHODS ASP structure and process were evaluated through an online survey in 148/152 acute hospitals in 2017. Scores were assigned to quality indicators based on resource- and labour-intensiveness, and their association with total and modified WHO-categorized 'Access', 'Watch' and 'Reserve' (AwaRe) prescribing was analysed. RESULTS The survey response rate was 97% with 78% of trusts submitting antimicrobial prescribing data. Over 80% of ASPs contained stewardship teams, policies and access to outpatient parenteral antimicrobial therapy, whilst less than 50% scored well for leadership or funding. High process performance was observed for antimicrobial pre-authorization, prescribing review and feedback, restricted susceptibility reporting, antimicrobial consumption monitoring, adherence to guidelines and junior doctor training. Low process attainment included education of senior prescribers and lack of resistance surveillance data distribution. Between 2016 and 2017, there was no difference in total trust prescribing (P = 0.117) although carbapenem prescribing fell (incidence rate ratio = 0.93, 95% CI 0.88-0.98) in non-teaching hospitals; 'Watch' prescribing also increased for specialist hospitals (OR = 1.10, 95% CI 1.01-1.20), as did 'Reserve' category prescribing in teaching (OR = 1.58, 95% CI 1.23-3.02) and specialist hospitals (OR = 3.09, 95% CI 2.02-4.74). A high process score was associated with lower 'Reserve' prescribing (OR = 0.82, 95% CI 0.67-1.01). CONCLUSIONS All responding trusts had established ASPs. The association of a scoring system with total and 'AWaRe' prescribing to assess effectiveness of ASPs merits further study.
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Affiliation(s)
- Antonia Scobie
- Reference Microbiology, National Infection Service, Public Health England, 61 Colindale Avenue, London, UK
| | - Emma L Budd
- Healthcare-Associated Infection & Antimicrobial Resistance Division, National Infection Service, Public Health England, 61 Colindale Avenue, London, UK
| | - Ross J Harris
- Statistics, Modelling and Economics Department, National Infection Service, Public Health England, 61 Colindale Avenue, London, UK
| | - Susan Hopkins
- Healthcare-Associated Infection & Antimicrobial Resistance Division, National Infection Service, Public Health England, 61 Colindale Avenue, London, UK
| | - Nandini Shetty
- Reference Microbiology, National Infection Service, Public Health England, 61 Colindale Avenue, London, UK
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11
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Shaw L. Representing antibiotic relationships using measurements of efficacy against clinical isolates. Wellcome Open Res 2019; 4:86. [PMID: 32995554 PMCID: PMC7520714 DOI: 10.12688/wellcomeopenres.15304.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2019] [Indexed: 03/30/2024] Open
Abstract
Introduction. Antimicrobial resistance (AMR) is a worrying and confusing problem for both patients and medical professionals. Current antimicrobial nomenclature makes it difficult to understand how different antibiotics are related to one another, and their empirical uses and efficacy. Here, I attempt to address this problem by using experimental data from hundreds of thousands of clinical isolates to infer relationships between antibiotics and represent them with simple diagrams. Methods. The minimum inhibitory concentration (MIC) of a bacterial isolate for a given antibiotic is defined as the lowest concentration that prevents visible growth. Measuring MICs for multiple antibiotics using the same isolate implicitly records the relationships of the antibiotics for a given species. The basic principle is that antibiotics with similar mechanisms of action should give rise to similar mechanisms of resistance, so should have correlated MICs across large numbers of isolates. This information can then be used to calculate distances between antibiotics based on pairwise correlations of their rank-ordered MICs. I apply this approach to a large historical AMR surveillance dataset (the Pfizer ATLAS surveillance dataset, 2004-2017). Results. I demonstrate that clustering antibiotics in this way allows a simple visual comparison of how similar antibiotics are to each other based on their efficacy within a species. The resulting visualizations broadly recapitulate antibiotic classes. They also clearly show the dramatic effects of combining beta-lactam antibiotics with beta-lactamase inhibitors, as well as highlighting antibiotics which have unexpected correlations in MICs that are not predicted from their chemical similarities alone. Conclusion. Large AMR surveillance datasets can be used in a hypothesis-free manner to show relationships between antibiotics based on their real-world efficacy. The resulting 'data-driven' diagrams could be used as simple visual aids to explain the complexity of antibiotic relationships and AMR.
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Affiliation(s)
- Liam Shaw
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
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12
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Islam J, Ashiru-Oredope D, Budd E, Howard P, Walker AS, Hopkins S, Llewelyn MJ. A national quality incentive scheme to reduce antibiotic overuse in hospitals: evaluation of perceptions and impact. J Antimicrob Chemother 2019; 73:1708-1713. [PMID: 29506043 DOI: 10.1093/jac/dky041] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 01/20/2018] [Indexed: 11/13/2022] Open
Abstract
Background In 2016/2017, a financially linked antibiotic prescribing quality improvement initiative Commissioning for Quality and Innovation (AMR-CQUIN) was introduced across acute hospitals in England. This aimed for >1% reductions in DDDs/1000 admissions of total antibiotics, piperacillin/tazobactam and carbapenems compared with 2013/2014 and improved review of empirical antibiotic prescriptions. Objectives To assess perceptions of staff leading antimicrobial stewardship activity regarding the AMR-CQUIN, the investments made by hospitals to achieve it and how these related to achieving reductions in antibiotic use. Methods We invited antimicrobial stewardship leads at acute hospitals across England to complete a web-based survey. Antibiotic prescribing data were downloaded from the PHE Antimicrobial Resistance Local Indicators resource. Results Responses were received from 116/155 (75%) acute hospitals. Owing to yearly increases in antibiotic use, most trusts needed to make >5% reductions in antibiotic consumption to achieve the AMR-CQUIN goal of 1% reduction. Additional funding was made available at 23/113 (20%) trusts and, in 18 (78%), this was <10% of the AMR-CQUIN value. Nationally, the annual trend for increased antibiotic use reversed in 2016/2017. In 2014/2015, year-on-year changes were +3.7% (IQR -0.8%, +8.4%), +9.4% (+0.2%, +19.5%) and +5.8% (-6.2%, +18.2%) for total antibiotics, piperacillin/tazobactam and carbapenems, respectively, and +0.1% (-5.4%, +4.0%), -4.8% (-16.9%, +3.2%) and -8.0% (-20.2%, +4.0%) in 2016/2017. Hospitals where staff believed they could reduce antibiotic use were more likely to do so (P < 0.001). Conclusions Introducing the AMR-CQUIN was associated with a reduction in antibiotic use. For individual hospitals, achieving the AMR-CQUIN was associated with favourable perceptions of staff and not availability of funding.
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Affiliation(s)
- J Islam
- Department of Microbiology and Infection, Brighton and Sussex University Hospitals NHS Trust, Brighton BN2 5BE, UK.,Department of Global Health and Infection, Brighton and Sussex Medical School, Falmer BN1 9PS, UK
| | - D Ashiru-Oredope
- AMR Programme, Public Health England, Wellington House, 133-155 Waterloo Rd, London SE1 8UG, UK
| | - E Budd
- AMR Programme, Public Health England, Wellington House, 133-155 Waterloo Rd, London SE1 8UG, UK
| | - P Howard
- Department of Medicines Management and Pharmacy, Leeds Teaching Hospitals NHS Trust, Leeds LS9 7TF, UK.,Faculty of Medicine and Health, University of Leeds, Leeds LS2 9JT, UK
| | - A S Walker
- Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - S Hopkins
- AMR Programme, Public Health England, Wellington House, 133-155 Waterloo Rd, London SE1 8UG, UK
| | - M J Llewelyn
- Department of Microbiology and Infection, Brighton and Sussex University Hospitals NHS Trust, Brighton BN2 5BE, UK.,Department of Global Health and Infection, Brighton and Sussex Medical School, Falmer BN1 9PS, UK
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13
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Walker AS, Budgell E, Laskawiec-Szkonter M, Sivyer K, Wordsworth S, Quaddy J, Santillo M, Krusche A, Roope LSJ, Bright N, Mowbray F, Jones N, Hand K, Rahman N, Dobson M, Hedley E, Crook D, Sharland M, Roseveare C, Hobbs FDR, Butler C, Vaughan L, Hopkins S, Yardley L, Peto TEA, Llewelyn MJ. Antibiotic Review Kit for Hospitals (ARK-Hospital): study protocol for a stepped-wedge cluster-randomised controlled trial. Trials 2019; 20:421. [PMID: 31296255 PMCID: PMC6625068 DOI: 10.1186/s13063-019-3497-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 06/05/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND To ensure patients continue to get early access to antibiotics at admission, while also safely reducing antibiotic use in hospitals, one needs to target the continued need for antibiotics as more diagnostic information becomes available. UK Department of Health guidance promotes an initiative called 'Start Smart then Focus': early effective antibiotics followed by active 'review and revision' 24-72 h later. However in 2017, < 10% of antibiotic prescriptions were discontinued at review, despite studies suggesting that 20-30% of prescriptions could be stopped safely. METHODS/DESIGN Antibiotic Review Kit for Hospitals (ARK-Hospital) is a complex 'review and revise' behavioural intervention targeting healthcare professionals involved in antibiotic prescribing or administration in inpatients admitted to acute/general medicine (the largest consumers of non-prophylactic antibiotics in hospitals). The primary study objective is to evaluate whether ARK-Hospital can safely reduce the total antibiotic burden in acute/general medical inpatients by at least 15%. The primary hypotheses are therefore that the introduction of the behavioural intervention will be non-inferior in terms of 30-day mortality post-admission (relative margin 5%) for an acute/general medical inpatient, and superior in terms of defined daily doses of antibiotics per acute/general medical admission (co-primary outcomes). The unit of observation is a hospital organisation, a single hospital or group of hospitals organised with one executive board and governance framework (National Health Service trusts in England; health boards in Northern Ireland, Wales and Scotland). The study comprises a feasibility study in one organisation (phase I), an internal pilot trial in three organisations (phase II) and a cluster (organisation)-randomised stepped-wedge trial (phase III) targeting a minimum of 36 organisations in total. Randomisation will occur over 18 months from November 2017 with a further 12 months follow-up to assess sustainability. The behavioural intervention will be delivered to healthcare professionals involved in antibiotic prescribing or administration in adult inpatients admitted to acute/general medicine. Outcomes will be assessed in adult inpatients admitted to acute/general medicine, collected through routine electronic health records in all patients. DISCUSSION ARK-Hospital aims to provide a feasible, sustainable and generalisable mechanism for increasing antibiotic stopping in patients who no longer need to receive them at 'review and revise'. TRIAL REGISTRATION ISRCTN Current Controlled Trials, ISRCTN12674243 . Registered on 10 April 2017.
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Affiliation(s)
- Ann Sarah Walker
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Eric Budgell
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Magda Laskawiec-Szkonter
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Katy Sivyer
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jack Quaddy
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Marta Santillo
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - Adele Krusche
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - Laurence S. J. Roope
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Nicole Bright
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Fiona Mowbray
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - Nicola Jones
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Kieran Hand
- University of Southampton, Southampton, UK
- University Hospital Southampton NHS Trust, Southampton, UK
| | - Najib Rahman
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Melissa Dobson
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Emma Hedley
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Derrick Crook
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | | | - F. D. Richard Hobbs
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Chris Butler
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Susan Hopkins
- Royal Free London NHS Foundation Trust, London, UK
- National Infection Service, Public Health England, London, UK
| | - Lucy Yardley
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
- School of Psychological Science, University of Bristol, Clifton, UK
| | - Timothy E. A. Peto
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - on behalf of the ARK trial team
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- University of Southampton, Southampton, UK
- University Hospital Southampton NHS Trust, Southampton, UK
- St George’s, University of London, London, UK
- Southern Health NHS Foundation Trust, Southampton, UK
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- The Nuffield Trust, London, UK
- Royal Free London NHS Foundation Trust, London, UK
- School of Psychological Science, University of Bristol, Clifton, UK
- National Infection Service, Public Health England, London, UK
- Brighton and Sussex Medical School, Brighton, UK
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14
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Shaw L. Representing antibiotic relationships using measurements of efficacy against clinical isolates. Wellcome Open Res 2019; 4:86. [PMID: 32995554 PMCID: PMC7520714 DOI: 10.12688/wellcomeopenres.15304.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2019] [Indexed: 03/30/2024] Open
Abstract
Introduction. Antimicrobial resistance (AMR) is a worrying and confusing problem for both patients and medical professionals. Current antimicrobial nomenclature makes it difficult to understand how different antibiotics are related to one another, and their empirical uses and efficacy. Here, I attempt to address this problem by using experimental data from hundreds of thousands of clinical isolates to infer relationships between antibiotics and represent them with simple diagrams. Methods. The minimum inhibitory concentration (MIC) of a bacterial isolate for a given antibiotic is defined as the lowest concentration that prevents visible growth. Measuring MICs for multiple antibiotics using the same isolate implicitly records the relationships of the antibiotics for a given species. The basic principle is that antibiotics with similar activities have similar mechanisms of action. Therefore, they should produce similar resistances, so should have correlated MICs. This information can then be used to calculate distances between antibiotics based on pairwise correlations of their rank-ordered MICs. I apply this approach to a large historical AMR surveillance dataset (the Pfizer ATLAS surveillance dataset, 2004-2017). Results. I demonstrate that clustering antibiotics in this way allows a simple visual comparison of how similar antibiotics are to each other based on their efficacy within a species. The resulting visualizations broadly recapitulate antibiotic classes. They also clearly show the dramatic effects of combination therapies, as well as highlighting antibiotics which have unexpected correlations in MICs that are not predicted from their chemical similarities alone (i.e. suggesting co-occurring resistance mechanisms). Conclusion. Large AMR surveillance datasets can be used in a hypothesis-free manner to show relationships between antibiotics based on their real-world efficacy. The resulting 'data-driven' diagrams could be used as simple visual aids to explain the complexity of antibiotic relationships and AMR.
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Affiliation(s)
- Liam Shaw
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
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15
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Masterton RG, Bassetti M, Chastre J, MacDonald AG, Rello J, Seaton RA, Welte T, Wilcox MH, West P. Valuing antibiotics: The role of the hospital clinician. Int J Antimicrob Agents 2019; 54:16-22. [PMID: 31085298 DOI: 10.1016/j.ijantimicag.2019.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 04/23/2019] [Accepted: 05/08/2019] [Indexed: 10/26/2022]
Abstract
The global public health threat of antibiotic-resistant infections as well as the lack of new treatments in clinical development is a critical issue. Reasons for this include diminished commercial incentives for pharmaceutical companies to develop new antibiotics, which part-reflects a shift in antibiotic marketing paradigm from broad deployment to targeted therapy in relatively small patient populations. Such changes are encouraged by antimicrobial stewardship (AMS). Other factors include a lack of recognition in the traditional assessment of new antibiotics by regulators, health technology assessors and payers of the broad range of benefits of new agents, particularly their value to health care, economies and society. Recognising the seriousness of the situation, there have been recent changes and proposals by regulators for modification of the assessment process to accommodate a broader range of acceptable data supporting new drug applications. There is also increasing recognition by some payers of the societal benefit of new antibiotics and the need for financial incentives for those developing high-priority antibiotics. However, progress is slow, with recent publications focusing on industry and strategic perspectives rather than clinical implications. In this opinion piece, we therefore focus on clinicians and the practical steps they can take to drive and contribute to increasing awareness and understanding of the value of antibiotics. This includes identifying and gathering appropriate alternative data sources, educating on AMS and prescribing habits, and contributing to international antibiotic susceptibility surveillance models.
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Affiliation(s)
- Robert G Masterton
- Academy of Infection Management (AIM) Ltd., BioHub at Alderley Park, Alderley Edge, Cheshire SK10 4TG, UK.
| | - Matteo Bassetti
- Infectious Diseases Clinic, Department of Medicine University of Udine and Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Jean Chastre
- Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | | | - Jordi Rello
- Department of Critical Care, Vall d'Hebron Institut of Research, Centro de Investigacion Biomedica en Red (CIBERES), Barcelona, Spain
| | - R Andrew Seaton
- Department of Infectious Diseases, NHS Greater Glasgow and Clyde, and Scottish Antimicrobial Prescribing Group, UK
| | - Tobias Welte
- Department of Respiratory Medicine and German Center for Lung Research, Hannover Medical School, Hannover, Germany
| | - Mark H Wilcox
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust and University of Leeds, Leeds, UK
| | - Peter West
- Academy of Infection Management (AIM) Ltd., BioHub at Alderley Park, Alderley Edge, Cheshire SK10 4TG, UK
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16
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Johnston DN, Keshtkar F, Campbell W. The effect of re-audit and education on antibiotic prescribing practice at Causeway Hospital, Northern Ireland. Ir J Med Sci 2019; 188:1149-1153. [PMID: 30810949 DOI: 10.1007/s11845-019-01995-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 02/16/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Antimicrobial resistance is a growing global problem. There has been increasing emphasis on promoting antimicrobial stewardship. Accurate completion of antibiotic prescriptions, such as documentation of clinical indication and a stop/review date, helps promote antimicrobial stewardship. AIMS To investigate the impact of educational interventions on the completeness of antibiotic prescriptions at Causeway Hospital surgical unit. METHODS Inpatient drug prescription charts were audited to monitor the completeness of antibiotic prescriptions on the surgical unit. Two educational interventions were implemented, with a subsequent prospective re-audit carried out. RESULTS The completion of (1) "Stop date/Review date", (2) "What infection are you treating?", (3) "Cultures sent?", (4) "Printed name", (5) "Professional number", and (6) "Bleep number" fields within the inpatient drug charts increased noticeably in the re-audit. A paired t test, comparing all of the initial audit completion proportions with the re-audit completion proportions, demonstrated a statistically significant improvement (p < 0.05). CONCLUSIONS Educational interventions led to an improvement in the completeness of antibiotic prescriptions. This highlights the important role that continued audit and education play in the promotion of antimicrobial stewardship.
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Affiliation(s)
- David N Johnston
- Department of Surgery, Northern HSC Trust, Causeway Hospital, 4 Newbridge Road, Coleraine, BT52 1HS, Northern Ireland.
| | - Fatemeh Keshtkar
- Department of Surgery, Northern HSC Trust, Causeway Hospital, 4 Newbridge Road, Coleraine, BT52 1HS, Northern Ireland
| | - William Campbell
- Department of Surgery, Northern HSC Trust, Causeway Hospital, 4 Newbridge Road, Coleraine, BT52 1HS, Northern Ireland
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17
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Ashiru-Oredope D, Doble A, Akpan MR, Hansraj S, Shebl NA, Ahmad R, Hopkins S. Antimicrobial Stewardship Programmes in Community Healthcare Organisations in England: A Cross-Sectional Survey to Assess Implementation of Programmes and National Toolkits. Antibiotics (Basel) 2018; 7:E97. [PMID: 30405004 PMCID: PMC6316239 DOI: 10.3390/antibiotics7040097] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 10/29/2018] [Accepted: 10/31/2018] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE The aim of this study was to assess antimicrobial stewardship activities in Community Healthcare Organisations (CHOs) with focus on the implementation of the two national antimicrobial stewardship toolkits, TARGET (Treat Antibiotics Responsibly, Guidance, Education, Tools) and SSTF (Start Smart, then Focus). The study utilised a web-based survey comprising 34 questions concerning antimicrobial policies and awareness and implementation of antimicrobial stewardship toolkits. This was distributed to pharmacy teams in all 26 CHOs in England. Twenty CHOs (77%) responded. An antimicrobial stewardship (AMS) committee was active in 50% of CHOs; 25% employed a substantive pharmacist post and 70% had a local antibiotic policy. Fourteen of the responding CHOs were aware of both AMS toolkits, five organisations were aware of either SSTF or TARGET, and one organisation was not aware of either toolkit. Of the organisations aware of SSTF and TARGET, eight had formally reviewed both toolkits, though three had not reviewed either. Less than half of the respondents had developed local action plans for either toolkit. National guidance in England has focused attention on initiatives to improve AMS implementation in primary and secondary care; more work is required to embed AMS activities and the implementation of national AMS toolkit recommendations within CHOs.
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Affiliation(s)
| | - Anne Doble
- HCAI & AMR Division, Public Health England, London NW9 5EQ, UK.
| | - Mary Richard Akpan
- Department of Clinical and Pharmaceutical Sciences, University of Hertfordshire, Hatfield AL10 9AB, UK.
| | - Sejal Hansraj
- HCAI & AMR Division, Public Health England, London NW9 5EQ, UK.
| | - Nada Atef Shebl
- Department of Clinical and Pharmaceutical Sciences, University of Hertfordshire, Hatfield AL10 9AB, UK.
| | - Raheelah Ahmad
- NIHR Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College London, Hammersmith Campus, Du Cane Road, London W12 0NN, UK.
| | - Susan Hopkins
- HCAI & AMR Division, Public Health England, London NW9 5EQ, UK.
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18
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Vihta KD, Stoesser N, Llewelyn MJ, Quan TP, Davies T, Fawcett NJ, Dunn L, Jeffery K, Butler CC, Hayward G, Andersson M, Morgan M, Oakley S, Mason A, Hopkins S, Wyllie DH, Crook DW, Wilcox MH, Johnson AP, Peto TEA, Walker AS. Trends over time in Escherichia coli bloodstream infections, urinary tract infections, and antibiotic susceptibilities in Oxfordshire, UK, 1998-2016: a study of electronic health records. THE LANCET. INFECTIOUS DISEASES 2018; 18:1138-1149. [PMID: 30126643 DOI: 10.1016/s1473-3099(18)30353-0] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 05/21/2018] [Accepted: 05/24/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Escherichia coli bloodstream infections are increasing in the UK and internationally. The evidence base to guide interventions against this major public health concern is small. We aimed to investigate possible drivers of changes in the incidence of E coli bloodstream infection and antibiotic susceptibilities in Oxfordshire, UK, over the past two decades, while stratifying for time since hospital exposure. METHODS In this observational study, we used all available data on E coli bloodstream infections and E coli urinary tract infections (UTIs) from one UK region (Oxfordshire) using anonymised linked microbiological data and hospital electronic health records from the Infections in Oxfordshire Research Database (IORD). We estimated the incidence of infections across a two decade period and the annual incidence rate ratio (aIRR) in 2016. We modelled the data using negative binomial regression on the basis of microbiological, clinical, and health-care-exposure risk factors. We investigated infection severity, 30-day all-cause mortality, and community and hospital amoxicillin plus clavulanic acid (co-amoxiclav) use to estimate changes in bacterial virulence and the effect of antimicrobial resistance on incidence. FINDINGS From Jan 1, 1998, to Dec 31, 2016, 5706 E coli bloodstream infections occurred in 5215 patients, and 228 376 E coli UTIs occurred in 137 075 patients. 1365 (24%) E coli bloodstream infections were nosocomial (onset >48 h after hospital admission), 1132 (20%) were quasi-nosocomial (≤30 days after discharge), 1346 (24%) were quasi-community (31-365 days after discharge), and 1863 (33%) were community (>365 days after hospital discharge). The overall incidence increased year on year (aIRR 1·06, 95% CI 1·05-1·06). In 2016, 212 (41%) of 515 E coli bloodstream infections and 3921 (28%) of 13 792 E coli UTIs were co-amoxiclav resistant. Increases in E coli bloodstream infections were driven by increases in community (aIRR 1·10, 95% CI 1·07-1·13; p<0·0001) and quasi-community (aIRR 1·08, 1·07-1·10; p<0·0001) cases. 30-day mortality associated with E coli bloodstream infection decreased over time in the nosocomial (adjusted rate ratio [RR] 0·98, 95% CI 0·96-1·00; p=0·03) group, and remained stable in the quasi-nosocomial (adjusted RR 0·98, 0·95-1·00; p=0·06), quasi-community (adjusted RR 0·99, 0·96-1·01; p=0·32), and community (adjusted RR 0·99, 0·96-1·01; p=0·21) groups. Mortality was, however, substantial at 14-25% across all hospital-exposure groups. Co-amoxiclav-resistant E coli bloodstream infections increased in all groups across the study period (by 11-18% per year, significantly faster than co-amoxiclav-susceptible E coli bloodstream infections; pheterogeneity<0·0001), as did co-amoxiclav-resistant E coli UTIs (by 14-29% per year; pheterogeneity<0·0001). Previous year co-amoxiclav use in primary-care facilities was associated with increased subsequent year community co-amoxiclav-resistant E coli UTIs (p=0·003). INTERPRETATION Increases in E coli bloodstream infections in Oxfordshire are primarily community associated, with substantial co-amoxiclav resistance; nevertheless, we found little or no change in mortality. Focusing interventions on primary care facilities, particularly those with high co-amoxiclav use, could be effective in reducing the incidence of co-amoxiclav-resistant E coli bloodstream infections, in this region and more generally. FUNDING National Institute for Health Research.
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Affiliation(s)
- Karina-Doris Vihta
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK; National Institute for Health Research (NIHR) Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance, Oxford, UK.
| | - Nicole Stoesser
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Martin J Llewelyn
- Brighton and Sussex Medical School, University of Sussex, Falmer, UK
| | - T Phuong Quan
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK; National Institute for Health Research (NIHR) Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance, Oxford, UK
| | - Tim Davies
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK; National Institute for Health Research (NIHR) Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance, Oxford, UK
| | - Nicola J Fawcett
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Laura Dunn
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Katie Jeffery
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Chris C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Gail Hayward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Marcus Morgan
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sarah Oakley
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Amy Mason
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Susan Hopkins
- National Infection Service, Public Health England, Colindale, UK
| | - David H Wyllie
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Derrick W Crook
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK; National Institute for Health Research (NIHR) Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance, Oxford, UK; National Infection Service, Public Health England, Colindale, UK
| | - Mark H Wilcox
- Healthcare Associated Infections Research Group, University of Leeds, Leeds, UK
| | - Alan P Johnson
- National Institute for Health Research (NIHR) Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance, Oxford, UK; National Infection Service, Public Health England, Colindale, UK
| | - Tim E A Peto
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK; National Institute for Health Research (NIHR) Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance, Oxford, UK
| | - A Sarah Walker
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK; National Institute for Health Research (NIHR) Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance, Oxford, UK
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19
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Monnier AA, Eisenstein BI, Hulscher ME, Gyssens IC. Towards a global definition of responsible antibiotic use: results of an international multidisciplinary consensus procedure. J Antimicrob Chemother 2018; 73:vi3-vi16. [PMID: 29878216 PMCID: PMC5989615 DOI: 10.1093/jac/dky114] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background Conducted as part of the Driving Reinvestment in Research and Development and Responsible Antibiotic Use (DRIVE-AB) project, this study aimed to identify key elements for a global definition of responsible antibiotic use based on diverse stakeholder input. Methods A three-step RAND-modified Delphi method was applied. First, a systematic review of antibiotic stewardship literature and relevant organization web sites identified definitions and synonyms of responsible use. Identified elements of definitions were presented by questionnaire to a multidisciplinary international stakeholder panel for appraisal of their relevance. Finally, questionnaire results were discussed in a consensus meeting. Results The systematic review and the web site search identified 17 synonyms (e.g. appropriate, correct) and 22 potential elements to include in a definition of responsible use. Elements were grouped into patient-level (e.g. Indication, Documentation) or societal-level elements (e.g. Education, Future Effectiveness). Forty-eight stakeholders with diverse backgrounds [medical community, public health, patients, antibiotic research and development (R&D), regulators, governments] from 18 countries across all continents participated in the questionnaire. Based on relevance scores, 21 elements were retained, 9 were rephrased and 1 was added. Together, the 22 elements and associated best-practice descriptions comprise an exhaustive list of elements to be considered when defining responsible use. Conclusions Combination of concepts from the literature and stakeholder opinion led to an international multidisciplinary consensus on a global definition of responsible antibiotic use. The widely diverging perspectives of stakeholders providing input should ensure the comprehensiveness and relevance of the definition for both individual patients and society. An aspirational goal would be to address all elements.
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Affiliation(s)
- Annelie A Monnier
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Faculty of Medicine, Research Group of Immunology and Biochemistry, Hasselt University, Hasselt, Belgium
| | | | - Marlies E Hulscher
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Inge C Gyssens
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Faculty of Medicine, Research Group of Immunology and Biochemistry, Hasselt University, Hasselt, Belgium
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20
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Onakpoya IJ, Walker AS, Tan PS, Spencer EA, Gbinigie OA, Cook J, Llewelyn MJ, Butler CC. Overview of systematic reviews assessing the evidence for shorter versus longer duration antibiotic treatment for bacterial infections in secondary care. PLoS One 2018; 13:e0194858. [PMID: 29590188 PMCID: PMC5874047 DOI: 10.1371/journal.pone.0194858] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 03/12/2018] [Indexed: 01/01/2023] Open
Abstract
Our objective was to assess the clinical effectiveness of shorter versus longer duration antibiotics for treatment of bacterial infections in adults and children in secondary care settings, using the evidence from published systematic reviews. We conducted electronic searches in MEDLINE, Embase, Cochrane, and Cinahl. Our primary outcome was clinical resolution. The quality of included reviews was assessed using the AMSTAR criteria, and the quality of the evidence was rated using the GRADE criteria. We included 6 systematic reviews (n = 3,162). Four reviews were rated high quality, and two of moderate quality. In adults, there was no difference between shorter versus longer duration in clinical resolution rates for peritonitis (RR 1.03, 95% CI 0.98 to 1.09, I2 = 0%), ventilator-associated pneumonia (RR 0.93; 95% CI 0.81 to 1.08, I2 = 24%), or acute pyelonephritis and septic UTI (clinical failure: RR 1.00, 95% CI 0.46 to 2.18). The quality of the evidence was very low to moderate. In children, there was no difference in clinical resolution rates for pneumonia (RR 0.98, 95% CI 0.91 to 1.04, I2 = 48%), pyelonephritis (RR 0.95, 95% CI 0.88 to 1.04) and confirmed bacterial meningitis (RR 1.02, 95% CI 0.93 to 1.11, I2 = 0%). The quality of the evidence was low to moderate. In conclusion, there is currently a limited body of evidence to clearly assess the clinical benefits of shorter versus longer duration antibiotics in secondary care. High quality trials assessing strategies to shorten antibiotic treatment duration for bacterial infections in secondary care settings should now be a priority.
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Affiliation(s)
- Igho J. Onakpoya
- University of Oxford, Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Oxford, United Kingdom
- * E-mail:
| | - A. Sarah Walker
- University of Oxford, Nuffield Department of Medicine, Experimental Medicine Division, John Radcliffe Hospital, Oxford, United Kingdom
| | - Pui S. Tan
- University of Oxford, Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Oxford, United Kingdom
| | - Elizabeth A. Spencer
- University of Oxford, Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Oxford, United Kingdom
| | - Oghenekome A. Gbinigie
- University of Oxford, Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Oxford, United Kingdom
| | - Johanna Cook
- University of Oxford, Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Oxford, United Kingdom
| | - Martin J. Llewelyn
- Department of Microbiology and Infection, Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom
- Brighton and Sussex Medical School, Department of Global Health and Infection, Falmer, East Sussex, United Kingdom
| | - Christopher C. Butler
- University of Oxford, Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Oxford, United Kingdom
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21
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Shetty A, Macdonald SP, Keijzers G, Williams JM, Tang B, de Groot B, Thompson K, Fraser JF, Finfer S, Bellomo R, Iredell J. Review article: Sepsis in the emergency department - Part 2: Investigations and monitoring. Emerg Med Australas 2018; 30:4-12. [PMID: 29341498 DOI: 10.1111/1742-6723.12924] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 12/01/2017] [Indexed: 12/14/2022]
Abstract
Sepsis is characterised by organ dysfunction resulting from infection, with no reliable single objective test and current diagnosis based on clinical features and results of investigations. In the ED, investigations may be conducted to diagnose infection as the cause of the presenting illness, identify the source, distinguish sepsis from uncomplicated infection (i.e. without organ dysfunction) and/ or risk stratification. Appropriate sample collection for microbiological testing remains key for subsequent confirmation of diagnosis and rationalisation of antimicrobials. Routine laboratory investigations such as creatinine, bilirubin, platelet count and lactate are now critical elements in the diagnosis of sepsis and septic shock. With no biomarker sufficiently validated to rule out bacterial infection in the ED, there remains substantial interest in biomarkers representing various pathogenic pathways. New technologies for screening multiple genes and proteins are identifying unique network 'signatures' of clinical interest. Other future directions include rapid detection of bacterial DNA in blood, genes for antibiotic resistance and EMR-based computational biomarkers that collate multiple information sources. Reliable, cost-effective tests, validated in the ED to promptly and accurately identify sepsis, and to guide initial antibiotic choices, are important goals of current research efforts.
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Affiliation(s)
- Amith Shetty
- Emergency Department, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Stephen Pj Macdonald
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia.,Department of Emergency Medicine, Royal Perth Hospital, Perth, Western Australia, Australia.,Division of Emergency Medicine, The University of Western Australia, Perth, Western Australia, Australia
| | - Gerben Keijzers
- School of Medicine, Bond University, Gold Coast, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Julian M Williams
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Benjamin Tang
- Immunology Department, Westmead Millennium Institute for Medical Research, Sydney, New South Wales, Australia.,Nepean Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Bas de Groot
- Department of Emergency Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | - Kelly Thompson
- Critical Care and Trauma Division, George Institute for Global Health, Sydney, New South Wales, Australia
| | - John F Fraser
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia.,Intensive Care Unit, St Andrew's War Memorial Hospital, Brisbane, Queensland, Australia
| | - Simon Finfer
- Division of Critical Care, George Institute for Global Health, Sydney, New South Wales, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,School of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Jonathan Iredell
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia.,Infectious Diseases, Westmead Hospital, Western Sydney Local Health District, Sydney, New South Wales, Australia.,Institute of Clinical Pathology and Medical Research, Pathology West, Sydney, New South Wales, Australia
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22
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Ledda A, Price JR, Cole K, Llewelyn MJ, Kearns AM, Crook DW, Paul J, Didelot X. Re-emergence of methicillin susceptibility in a resistant lineage of Staphylococcus aureus. J Antimicrob Chemother 2018; 72:1285-1288. [PMID: 28108681 DOI: 10.1093/jac/dkw570] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 12/09/2016] [Indexed: 11/14/2022] Open
Abstract
Objectives MRSA is a leading cause of hospital-associated infection. Acquired resistance is encoded by the mecA gene or its homologue mecC , but little is known about the evolutionary dynamics involved in gain and loss of resistance. The objective of this study was to obtain an expanded understanding of Staphylococcus aureus methicillin resistance microevolution in vivo , by focusing on a single lineage. Methods We compared the whole-genome sequences of 231 isolates from a single epidemic lineage [clonal complex 30 (CC30) and spa -type t018] of S. aureus that caused an epidemic in the UK. Results We show that resistance to methicillin in this single lineage was gained on at least two separate occasions, one of which led to a clonal expansion around 1995 presumably caused by a selective advantage. Resistance was, however, subsequently lost in vivo by nine strains isolated between 2008 and 2012. We describe the genetic mechanisms involved in this loss of resistance and the imperfect relationship between genotypic and phenotypic resistance. Conclusions The recent re-emergence of methicillin susceptibility in this epidemic lineage suggests a significant fitness cost of resistance and reduced selective advantage following the introduction in the mid-2000s of MRSA hospital control measures throughout the UK.
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Affiliation(s)
- Alice Ledda
- Department of Infectious Disease Epidemiology, Imperial College London, Norfolk Place, London W2 1PG, UK
| | - James R Price
- Department of Infectious Diseases and Microbiology, Royal Sussex County Hospital, Brighton, UK
| | - Kevin Cole
- Department of Infectious Diseases and Microbiology, Royal Sussex County Hospital, Brighton, UK.,Public Health England, Microbiology, Royal Sussex County Hospital, Brighton, UK
| | - Martin J Llewelyn
- Department of Infectious Diseases and Microbiology, Royal Sussex County Hospital, Brighton, UK
| | - Angela M Kearns
- Antimicrobial Resistance and Healthcare Associated Infections Reference Unit, National Infection Service, Public Health England, Colindale, UK
| | - Derrick W Crook
- Nuffield Department of Medicine, University of Oxford, Oxford OX3 7BN, UK
| | - John Paul
- Public Health England, Microbiology, Royal Sussex County Hospital, Brighton, UK
| | - Xavier Didelot
- Department of Infectious Disease Epidemiology, Imperial College London, Norfolk Place, London W2 1PG, UK
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23
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Rockenschaub P, Ansell D, Shallcross L. Linking individual-level data on diagnoses and dispensing for research on antibiotic use: Evaluation of a novel data source from English secondary care. Pharmacoepidemiol Drug Saf 2017; 27:206-212. [PMID: 29230891 DOI: 10.1002/pds.4367] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 11/08/2017] [Accepted: 11/11/2017] [Indexed: 11/07/2022]
Abstract
PURPOSE There has been a focus on stewardship programmes to curb inappropriate antibiotic prescribing and reduce antimicrobial resistance. In-hospital, patient-level prescribing linked to indication is needed to support surveillance, evaluation of stewardship initiatives, as well as other antibiotic research. We evaluated whether a novel dataset linking hospital pharmacy records to Hospital Episode Statistics data can be used for antibiotic research. METHODS Using the Hospital Treatment Insights (HTI) database, which links Hospital Episode Statistics to pharmacy records from 43 out of 153 hospital trusts in England, we estimated the proportion of missed linkage and identified characteristics associated with missing data. RESULTS Linkage of antibiotics to patients was inconsistent and dependent on drug type and clinical setting, so that linkage for some specific antibiotics was high (80-100%), but overall, only 27.6% (CI: 27.4%-27.8%) for all antibiotics dispensed. Linkage was best for quinolones (62.6%; CI: 61.8%-63.8%), but only 21.1% (CI: 21.1%-21.2%) for penicillins. Linkage was lower for common antibiotics and in emergency departments; however, 80% linkage was achieved for individual drugs like clindamycin, especially on wards with reduced ward stock use. CONCLUSIONS For those antibiotics with high linkage, HTI might be used to study associations between indication, dispensing, and outcomes. However, the majority of common antibiotics had insufficient linkage, likely due to extensive use of ward stocks. Therefore, HTI in its current form is not suitable for general antibiotic surveillance or evaluation of stewardship initiatives. For drugs in HTI other than antibiotics, linkage should be similarly evaluated before a study is conducted.
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Affiliation(s)
- Patrick Rockenschaub
- Institute of Health Informatics, University College London, London, UK.,QuintilesIMS, London, UK
| | | | - Laura Shallcross
- Institute of Health Informatics, University College London, London, UK
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24
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de Kraker MEA, Abbas M, Huttner B, Harbarth S. Good epidemiological practice: a narrative review of appropriate scientific methods to evaluate the impact of antimicrobial stewardship interventions. Clin Microbiol Infect 2017; 23:819-825. [PMID: 28571767 DOI: 10.1016/j.cmi.2017.05.019] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 05/15/2017] [Accepted: 05/17/2017] [Indexed: 12/30/2022]
Abstract
AIMS In this narrative review, we provide a framework for assessing the quality of evidence provided by studies investigating antimicrobial stewardship (AMS) interventions, and inform the design and planning stage for future AMS evaluation studies to determine the best strategies to keep antimicrobial resistance at bay. SOURCES Cochrane/Pubmed. CONTENT As AMS is mostly applied in a complex, real-world setting, bias and random time effects can jeopardize the validity of causal inference. The most important risks include simultaneously implemented infection prevention strategies and regression to the mean. Inclusion of homogeneous intervention and control arms, through randomization of the intervention, can limit these risks. However, contamination can play an important role for AMS; therefore, randomization at cluster-level, instead of randomization at individual-level, is recommended. It can be challenging to identify enough representative clusters, and implementation of a cluster-RCT (cRCT) can be costly. Controlled interrupted time series (ITS) design has a high validity as well, and is relatively straightforward to implement, although time-varying confounding should be considered. Independent of the study design, it is crucial to include multiple process, clinical outcome, microbiological and financial measures, to be able to detect possible, unintended consequences. IMPLICATIONS Future studies assessing the impact of new AMS strategies should produce compelling evidence by opting for cRCTs, or ITS including a control arm. Furthermore, a holistic view of intended and unintended consequences should be reported, and a detailed process evaluation should be provided to adequately inform implementation of successful AMS strategies to battle the rising burden of AMR.
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Affiliation(s)
- M E A de Kraker
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.
| | - M Abbas
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - B Huttner
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland; Division of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - S Harbarth
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland; Division of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
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25
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Soop M, Carlson GL. Recent developments in the surgical management of complex intra-abdominal infection. Br J Surg 2017; 104:e65-e74. [PMID: 28121035 DOI: 10.1002/bjs.10437] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 10/26/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Current guidance on the management of sepsis often applies to infection originating from abdominal or pelvic sources, which presents specific challenges and opportunities for efficient and rapid source control. Advances made in the past decade are presented in this article. METHODS A qualitative systematic review was undertaken by searching standard literature databases for English-language studies presenting original data on the clinical management of abdominal and pelvic complex infection in adults over the past 10 years. High-quality studies relevant to five topical themes that emerged during review were included. RESULTS Important developments and promising preliminary work are presented, relating to: imaging and other diagnostic modalities; antimicrobial therapy and the importance of antimicrobial stewardship; the particular challenges posed by fungal sepsis; novel techniques in percutaneous and endoscopic source control; and current issues relating to surgical source control and managing the abdominal wound. Logistical challenges relating to rapid access to cross-sectional imaging, interventional radiology and operating theatres need to be addressed so that international benchmarks can be met. CONCLUSION Important advances have been made in the diagnosis, non-operative and surgical control of abdominal or pelvic sources, which may improve outcomes in the future. Important areas for continued research include the diagnosis and therapy of fungal infection and the challenges of managing the open abdomen.
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Affiliation(s)
- M Soop
- Intestinal Failure Unit, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - G L Carlson
- Intestinal Failure Unit, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
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26
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Risk factors for Clostridium difficile infection in hospitalized patients with community-acquired pneumonia. J Infect 2016; 73:45-53. [PMID: 27105657 DOI: 10.1016/j.jinf.2016.04.008] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 04/06/2016] [Accepted: 04/11/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Clostridium difficile infection (CDI) is strongly associated with anti-biotic treatment, and community-acquired pneumonia (CAP) is the leading indication for anti-biotic prescription in hospitals. This study assessed the incidence of and risk factors for CDI in a cohort of patients hospitalized with CAP. METHODS We analysed data from a prospective, observational cohort of patients with CAP in Edinburgh, UK. Patients with diarrhoea were systematically screened for CDI, and risk factors were determined through time-dependent survival analysis. RESULTS Overall, 1883 patients with CAP were included, 365 developed diarrhoea and 61 had laboratory-confirmed CDI. The risk factors for CDI were: age (hazard ratio [HR], 1.06 per year; 95% confidence interval [CI], 1.03-1.08), total number of antibiotic classes received (HR, 3.01 per class; 95% CI, 2.32-3.91), duration of antibiotic therapy (HR, 1.09 per day; 95% CI, 1.00-1.19 and hospitalization status (HR, 13.1; 95% CI, 6.0-28.7). Antibiotic class was not an independent predictor of CDI when adjusted for these risk factors (P > 0.05 by interaction testing). CONCLUSIONS These data suggest that reducing the overall antibiotic burden, duration of antibiotic treatment and duration of hospital stay may reduce the incidence of CDI in patients with CAP.
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27
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Shallcross LJ, Freemantle N, Nisar S, Ray D. A cross-sectional study of blood cultures and antibiotic use in patients admitted from the Emergency Department: missed opportunities for antimicrobial stewardship. BMC Infect Dis 2016; 16:166. [PMID: 27091375 PMCID: PMC4835863 DOI: 10.1186/s12879-016-1515-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 04/14/2016] [Indexed: 11/25/2022] Open
Abstract
Background Early review of antimicrobial prescribing decisions within 48 h is recommended to reduce the overall use of unnecessary antibiotics, and in particular the use of broad-spectrum antibiotics. When parenteral antibiotics are used, blood culture results provide valuable information to help decide whether to continue, alter or stop antibiotics at 48 h. The objective of this study was to investigate the frequency of parenteral antibiotic use, broad spectrum antibiotic use and use of blood cultures when parenteral antibiotics are initiated in patients admitted via the Emergency Department. Methods We used electronic health records from patients admitted from the Emergency Department at University Hospital Birmingham in 2014. Results Six percent (4562/72939) of patients attending the Emergency department and one-fifth (4357/19034) of those patients admitted to hospital were prescribed a parenteral antimicrobial. More than half of parenteral antibiotics used were either co-amoxiclav or piperacillin-tazobactam. Blood cultures were obtained in less than one-third of patients who were treated with a parenteral antibiotic. Conclusions Parenteral antibiotics are frequently used in those admitted from the Emergency Department; they are usually broad spectrum and are usually initiated without first obtaining cultures. Blood cultures may have limited value to support prescribing review as part of antimicrobial stewardship initiatives.
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Affiliation(s)
- Laura J Shallcross
- UCL Centre for Infectious Disease Informatics, Farr Institute of Health Informatics Research, 222 Euston Road, London, NW1 2DA, UK.
| | - Nick Freemantle
- Department of Primary Care and Population Health, Upper Third floor, UCL Medical School, Rowland Hill Street, London, NW3 2PF, UK
| | - Shasta Nisar
- Health Informatics, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Queen Elizabeth Medical Centre, Birmingham, B15 2TH, UK
| | - Daniel Ray
- UCL Centre for Infectious Disease Informatics, Farr Institute of Health Informatics Research, 222 Euston Road, London, NW1 2DA, UK.,Health Informatics, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Queen Elizabeth Medical Centre, Birmingham, B15 2TH, UK
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28
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Quan TP, Fawcett NJ, Wrightson JM, Finney J, Wyllie D, Jeffery K, Jones N, Shine B, Clarke L, Crook D, Walker AS, Peto TEA. Increasing burden of community-acquired pneumonia leading to hospitalisation, 1998-2014. Thorax 2016; 71:535-42. [PMID: 26888780 PMCID: PMC4893127 DOI: 10.1136/thoraxjnl-2015-207688] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 12/23/2015] [Indexed: 11/03/2022]
Abstract
BACKGROUND Community-acquired pneumonia (CAP) is a major cause of mortality and morbidity in many countries but few recent large-scale studies have examined trends in its incidence. METHODS Incidence of CAP leading to hospitalisation in one UK region (Oxfordshire) was calculated over calendar time using routinely collected diagnostic codes, and modelled using piecewise-linear Poisson regression. Further models considered other related diagnoses, typical administrative outcomes, and blood and microbiology test results at admission to determine whether CAP trends could be explained by changes in case-mix, coding practices or admission procedures. RESULTS CAP increased by 4.2%/year (95% CI 3.6 to 4.8) from 1998 to 2008, and subsequently much faster at 8.8%/year (95% CI 7.8 to 9.7) from 2009 to 2014. Pneumonia-related conditions also increased significantly over this period. Length of stay and 30-day mortality decreased slightly in later years, but the proportions with abnormal neutrophils, urea and C reactive protein (CRP) did not change (p>0.2). The proportion with severely abnormal CRP (>100 mg/L) decreased slightly in later years. Trends were similar in all age groups. Streptococcus pneumoniae was the most common causative organism found; however other organisms, particularly Enterobacteriaceae, increased in incidence over the study period (p<0.001). CONCLUSIONS Hospitalisations for CAP have been increasing rapidly in Oxfordshire, particularly since 2008. There is little evidence that this is due only to changes in pneumonia coding, an ageing population or patients with substantially less severe disease being admitted more frequently. Healthcare planning to address potential further increases in admissions and consequent antibiotic prescribing should be a priority.
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Affiliation(s)
- T Phuong Quan
- NIHR Oxford Biomedical Research Centre, Oxford, UK Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Nicola J Fawcett
- NIHR Oxford Biomedical Research Centre, Oxford, UK Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - John M Wrightson
- NIHR Oxford Biomedical Research Centre, Oxford, UK Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - John Finney
- NIHR Oxford Biomedical Research Centre, Oxford, UK Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - David Wyllie
- NIHR Oxford Biomedical Research Centre, Oxford, UK Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Katie Jeffery
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Nicola Jones
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Brian Shine
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Lorraine Clarke
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Derrick Crook
- NIHR Oxford Biomedical Research Centre, Oxford, UK Nuffield Department of Medicine, University of Oxford, Oxford, UK Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - A Sarah Walker
- NIHR Oxford Biomedical Research Centre, Oxford, UK Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Timothy E A Peto
- NIHR Oxford Biomedical Research Centre, Oxford, UK Nuffield Department of Medicine, University of Oxford, Oxford, UK Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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29
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Ashiru-Oredope D, Budd EL, Bhattacharya A, Din N, McNulty CAM, Micallef C, Ladenheim D, Beech E, Murdan S, Hopkins S. Implementation of antimicrobial stewardship interventions recommended by national toolkits in primary and secondary healthcare sectors in England: TARGET and Start Smart Then Focus. J Antimicrob Chemother 2016; 71:1408-14. [PMID: 26869693 DOI: 10.1093/jac/dkv492] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 12/22/2015] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES To assess and compare the implementation of antimicrobial stewardship (AMS) interventions recommended within the national AMS toolkits, TARGET and Start Smart Then Focus, in English primary and secondary healthcare settings in 2014, to determine the prevalence of cross-sector engagement to drive AMS interventions and to propose next steps to improve implementation of AMS. METHODS Electronic surveys were circulated to all 211 clinical commissioning groups (CCGs; primary sector) and to 146 (out of the 159) acute trusts (secondary sector) in England. Response rates were 39% and 63% for the primary and secondary sectors, respectively. RESULTS The majority of CCGs and acute trusts reported reviewing national AMS toolkits formally or informally (60% and 87%, respectively). However, only 13% of CCGs and 46% of acute trusts had developed an action plan for the implementation of these toolkits. Only 5% of CCGs had antimicrobial pharmacists in post; however, the role of specialist antimicrobial pharmacists continued to remain embedded within acute trusts, with 83% of responding trusts having an antimicrobial pharmacist at a senior grade. CONCLUSIONS The majority of healthcare organizations review national AMS toolkits; however, implementation of the toolkits, through the development of action plans to deliver AMS interventions, requires improvement. For the first time, we report the extent of cross-sector and multidisciplinary collaboration to deliver AMS interventions in both primary and secondary care sectors in England. Results highlight that further qualitative and quantitative work is required to explore mutual benefits and promote best practice. Antimicrobial pharmacists remain leaders for implementing AMS interventions across both primary and secondary healthcare sectors.
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Affiliation(s)
- D Ashiru-Oredope
- Antimicrobial Resistance Programme, Public Health England, London, UK
| | - E L Budd
- Antimicrobial Resistance Programme, Public Health England, London, UK
| | - A Bhattacharya
- Antimicrobial Resistance Programme, Public Health England, London, UK
| | - N Din
- Department of Pharmaceutics, UCL School of Pharmacy, UCL, London, UK
| | - C A M McNulty
- Primary Care Unit, Public Health England, Gloucester Royal Hospital, Gloucester, UK
| | - C Micallef
- Pharmacy Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK National Institute for Health Research Health Protection Research Unit, Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London, UK
| | - D Ladenheim
- Pharmacy Department, East & North Herts NHS Trust, Hertford, UK
| | - E Beech
- NHS Bath and North East Somerset Clinical Commissioning Group, Bath, UK NHS England Patient Safety Domain 5, London, UK
| | - S Murdan
- Department of Pharmaceutics, UCL School of Pharmacy, UCL, London, UK
| | - S Hopkins
- Antimicrobial Resistance Programme, Public Health England, London, UK
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Fitzpatrick JM, Biswas JS, Edgeworth JD, Islam J, Jenkins N, Judge R, Lavery AJ, Melzer M, Morris-Jones S, Nsutebu EF, Peters J, Pillay DG, Pink F, Price JR, Scarborough M, Thwaites GE, Tilley R, Walker AS, Llewelyn MJ. Gram-negative bacteraemia; a multi-centre prospective evaluation of empiric antibiotic therapy and outcome in English acute hospitals. Clin Microbiol Infect 2015; 22:244-51. [PMID: 26577143 DOI: 10.1016/j.cmi.2015.10.034] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 10/23/2015] [Accepted: 10/31/2015] [Indexed: 10/22/2022]
Abstract
Increasing antibiotic resistance makes choosing antibiotics for suspected Gram-negative infection challenging. This study set out to identify key determinants of mortality among patients with Gram-negative bacteraemia, focusing particularly on the importance of appropriate empiric antibiotic treatment. We conducted a prospective observational study of 679 unselected adults with Gram-negative bacteraemia at ten acute english hospitals between October 2013 and March 2014. Appropriate empiric antibiotic treatment was defined as intravenous treatment on the day of blood culture collection with an antibiotic to which the cultured organism was sensitive in vitro. Mortality analyses were adjusted for patient demographics, co-morbidities and illness severity. The majority of bacteraemias were community-onset (70%); most were caused by Escherichia coli (65%), Klebsiella spp. (15%) or Pseudomonas spp. (7%). Main foci of infection were urinary tract (51%), abdomen/biliary tract (20%) and lower respiratory tract (14%). The main antibiotics used were co-amoxiclav (32%) and piperacillin-tazobactam (30%) with 34% receiving combination therapy (predominantly aminoglycosides). Empiric treatment was inappropriate in 34%. All-cause mortality was 8% at 7 days and 15% at 30 days. Independent predictors of mortality (p <0.05) included older age, greater burden of co-morbid disease, severity of illness at presentation and inflammatory response. Inappropriate empiric antibiotic therapy was not associated with mortality at either time-point (adjusted OR 0.82; 95% CI 0.35-1.94 and adjusted OR 0.92; 95% CI 0.50-1.66, respectively). Although our study does not exclude an impact of empiric antibiotic choice on survival in Gram-negative bacteraemia, outcome is determined primarily by patient and disease factors.
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Affiliation(s)
- J M Fitzpatrick
- Department of Infectious Diseases and Microbiology, Royal Sussex County Hospital, Brighton, UK
| | - J S Biswas
- Centre for Clinical Infection and Diagnostics Research, Department of Infectious Diseases, Kings College London and Guy's and St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - J D Edgeworth
- Centre for Clinical Infection and Diagnostics Research, Department of Infectious Diseases, Kings College London and Guy's and St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - J Islam
- Department of Microbiology, Surrey and Sussex Healthcare NHS Trust, Redhill, UK
| | - N Jenkins
- Department of Microbiology, Infection and Tropical Medicine, Heart of England NHS Trust, Birmingham, UK
| | - R Judge
- Department of Microbiology, Plymouth Hospitals NHS Trust, Plymouth, UK
| | - A J Lavery
- Department of Clinical Microbiology and Virology, UCLH NHS Foundation Trust, London, UK
| | - M Melzer
- Department of Infection, Barts Health NHS Trust, London, UK
| | - S Morris-Jones
- Department of Clinical Microbiology and Virology, UCLH NHS Foundation Trust, London, UK
| | - E F Nsutebu
- Tropical and Infectious Disease Unit Royal Liverpool University Hospital, Liverpool, UK
| | - J Peters
- Department of Infectious Diseases and Microbiology, Royal Sussex County Hospital, Brighton, UK
| | - D G Pillay
- Department of Microbiology, Infection and Tropical Medicine, Heart of England NHS Trust, Birmingham, UK
| | - F Pink
- Department of Infection, Barts Health NHS Trust, London, UK
| | - J R Price
- Department of Microbiology, Western Sussex Hospitals NHS Foundation Trust, Chichester, UK
| | - M Scarborough
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
| | - G E Thwaites
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - R Tilley
- Department of Microbiology, Plymouth Hospitals NHS Trust, Plymouth, UK
| | - A S Walker
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK; Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - M J Llewelyn
- Department of Infectious Diseases and Microbiology, Royal Sussex County Hospital, Brighton, UK; Division of Medicine, Brighton and Sussex Medical School, Falmer, UK.
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31
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Molina J, Cisneros JM. Editorial Commentary: A Chance to Change the Paradigm of Outcome Assessment of Antimicrobial Stewardship Programs. Clin Infect Dis 2015; 61:807-8. [PMID: 26113651 DOI: 10.1093/cid/civ496] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 06/13/2015] [Indexed: 01/22/2023] Open
Affiliation(s)
- Jose Molina
- Department of Infectious Diseases, Microbiology, and Preventive Medicine, Institute of Biomedicine of Seville, University Hospital Virgen del Rocio, Spain
| | - Jose M Cisneros
- Department of Infectious Diseases, Microbiology, and Preventive Medicine, Institute of Biomedicine of Seville, University Hospital Virgen del Rocio, Spain
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Bert F, Scaioli G, Gualano MR, Siliquini R. How can we bring public health in all policies? Strategies for healthy societies. J Public Health Res 2015; 4:393. [PMID: 25918692 PMCID: PMC4407037 DOI: 10.4081/jphr.2015.393] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 01/21/2015] [Indexed: 11/22/2022] Open
Abstract
New scenarios are emerging in the European and worldwide context: the ageing of society, the climate changes, the increasing of health inequalities and the financial crisis. In this context, the scientific community and the decision-makers agree on the role of health in all policies (HiAP) strategy in improving the population's health. The HiAP takes into account factors not strictly related to health but with important health consequences. To bring public health in all policies a change is needed, but there are some obstacles to overcome: for instance, the lack of evidence regarding the governance tools and frameworks for HiAP, the difficulty of convincing stakeholders and producing a cultural change in the political positioning of decision-makers. Consequently, it is necessary: i) to implement stronger and responsible decision-support approaches, such as health impact assessment and health technology assessment; ii) to encourage and coordinate all relevant sectors in playing their part in reducing health gaps within the European Union; iii) to strengthen cooperation and make better use of existing networks and existing public health and related institutions. The final aim will be to monitor the impact of the health determinants in order to promote the effective implementation of HiAP approach. Significance for public healthThis paper makes public health professionals aware of the pivotal role that they could play in reducing health inequalities and in helping to overcome the crisis of the European health systems. It discusses how, thanks to a systematic approach based on new instruments like health impact assessment and health technology assessment, and thanks also to a stronger cooperation among stakeholders and policy makers, it is possible to monitor the health determinants and consequently to bring health in all policies.
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Affiliation(s)
- Fabrizio Bert
- Department of Public Health, University of Turin, Italy
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