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Sandoe JAT, Grozeva D, Albur M, Bond SE, Brookes-Howell L, Dark P, Euden J, Hamilton R, Hellyer TP, Henley J, Hopkins S, Howard P, Howdon D, Knox-Macaulay C, Llewelyn MJ, Maboshe W, McCullagh IJ, Ogden M, Parsons HK, Partridge DG, Powell N, Prestwich G, Shaw D, Shinkins B, Szakmany T, Thomas-Jones E, Todd S, West RM, Carrol ED, Pallmann P. A retrospective propensity-score-matched cohort study of the impact of procalcitonin testing on antibiotic use in hospitalized patients during the first wave of COVID-19. J Antimicrob Chemother 2024:dkae246. [PMID: 39248146 DOI: 10.1093/jac/dkae246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 06/14/2024] [Indexed: 09/10/2024] Open
Abstract
BACKGROUND Procalcitonin (PCT) is a blood marker used to help diagnose bacterial infections and guide antibiotic treatment. PCT testing was widely used/adopted during the COVID-19 pandemic in the UK. OBJECTIVES Primary: to measure the difference in length of early (during first 7 days) antibiotic prescribing between patients with COVID-19 who did/did not have baseline PCT testing during the first wave of the pandemic. Secondary: to measure differences in length of hospital/ICU stay, mortality, total days of antibiotic prescribing and resistant bacterial infections between these groups. METHODS Multi-centre, retrospective, observational, cohort study using patient-level clinical data from acute hospital Trusts/Health Boards in England/Wales. Inclusion: patients ≥16 years, admitted to participating Trusts/Health Boards and with a confirmed positive COVID-19 test between 1 February 2020 and 30 June 2020. RESULTS Data from 5960 patients were analysed: 1548 (26.0%) had a baseline PCT test and 4412 (74.0%) did not. Using propensity-score matching, baseline PCT testing was associated with an average reduction in early antibiotic prescribing of 0.43 days [95% confidence interval (CI): 0.22-0.64 days, P < 0.001) and of 0.72 days (95% CI: 0.06-1.38 days, P = 0.03] in total antibiotic prescribing. Baseline PCT testing was not associated with increased mortality or hospital/ICU length of stay or with the rate of antimicrobial-resistant secondary bacterial infections. CONCLUSIONS Baseline PCT testing appears to have been an effective antimicrobial stewardship tool early in the pandemic: it reduced antibiotic prescribing without evidence of harm. Our study highlights the need for embedded, rapid evaluations of infection diagnostics in the National Health Service so that even in challenging circumstances, introduction into clinical practice is supported by evidence for clinical utility. STUDY REGISTRATION NUMBER ISRCTN66682918.
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Affiliation(s)
- Jonathan A T Sandoe
- Department of Microbiology, The General Infirmary at Leeds, Leeds, UK
- Healthcare Associated Infection Group, Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - Detelina Grozeva
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Mahableshwar Albur
- Department of Infection Sciences, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Stuart E Bond
- Pharmacy Department, Mid Yorkshire Teaching NHS Trust, Wakefield, UK
| | - Lucy Brookes-Howell
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Paul Dark
- Division of Immunology, Immunity to Infection and Respiratory Medicine, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Joanne Euden
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Ryan Hamilton
- Antibiotic Research UK, York, UK
- School of Pharmacy, De Montfort University, Leicester, UK
| | - Thomas P Hellyer
- Royal Victoria Infirmary, Newcastle and Freeman Hospital, Newcastle-upon-Tyne Hospital NHS Foundation Trust, Newcastle-upon-Tyne, UK
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle, UK
| | - Josie Henley
- School of Social Sciences, Cardiff University, Cardiff, UK
| | | | - Philip Howard
- NHS England and NHS Improvement, North-East and Yorkshire Region, UK
| | - Daniel Howdon
- Leeds Institute for Health Sciences, University of Leeds, Leeds, UK
| | - Chikezie Knox-Macaulay
- Public and Patient Involvement Representative, Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Martin J Llewelyn
- Brighton and Sussex Medical School, University of Sussex and University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Wakunyambo Maboshe
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Iain J McCullagh
- Royal Victoria Infirmary, Newcastle and Freeman Hospital, Newcastle-upon-Tyne Hospital NHS Foundation Trust, Newcastle-upon-Tyne, UK
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle, UK
| | - Margaret Ogden
- Public and Patient Involvement Representative, Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Helena K Parsons
- Department of Microbiology, Laboratory Medicine, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - David G Partridge
- Department of Microbiology, Laboratory Medicine, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Neil Powell
- Pharmacy Department, Royal Cornwall Hospitals NHS Foundation Trust, Truro, UK
| | - Graham Prestwich
- Public and Patient Involvement Representative, Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Dominick Shaw
- Leicester NIHR Biomedical Research Centre and Department of Respiratory Sciences, University of Leicester, Leicester, UK
| | - Bethany Shinkins
- Leeds Institute for Health Sciences, University of Leeds, Leeds, UK
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Tamas Szakmany
- Critical Care Directorate, Aneurin Bevan University Health Board, Cwmbran, UK
- Department of Anaesthesia, Intensive Care and Pain Medicine, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Emma Thomas-Jones
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Stacy Todd
- Tropical and Infectious Disease Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Robert M West
- Leeds Institute for Health Sciences, University of Leeds, Leeds, UK
| | - Enitan D Carrol
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
| | - Philip Pallmann
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
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Raavi L, Isha S, Jonna S, Craver EC, Nataraja H, Jenkins A, Hanson AJ, Venkataraman AB, Balasubramanian P, Tekin A, Bansal V, Caples SM, Khan SA, Jain NK, LaNou AT, Kashyap R, Cartin-Ceba R, Patel BM, Milian RD, Venegas CP, Shapiro AB, Bhattacharyya A, Chaudhary S, Kiley SP, Erben YM, Quinones QJ, Patel NM, Guru PK, Franco PM, Roy A, Sanghavi DK. Association of antibiotics with the outcomes in COVID-19 pneumonia patients with elevated PCT levels. Respir Med 2024; 231:107697. [PMID: 38857810 DOI: 10.1016/j.rmed.2024.107697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 05/29/2024] [Accepted: 06/05/2024] [Indexed: 06/12/2024]
Abstract
OBJECTIVE To assess antibiotics impact on outcomes in COVID-19 pneumonia patients with varying procalcitonin (PCT) levels. METHODS This retrospective cohort study included 3665 COVID-19 pneumonia patients hospitalized at five Mayo Clinic sites (March 2020 to June 2022). PCT levels were measured at admission. Patients' antibiotics use and outcomes were collected via the Society of Critical Care Medicine (SCCM) Viral Infection and Respiratory Illness Universal Study (VIRUS) registry. Patients were stratified into high and low PCT groups based on the first available PCT result. The distinction between high and low PCT was demarcated at both 0.25 ng/ml and 0.50 ng/ml. RESULTS Our cohort consisted of 3665 patients admitted with COVID-19 pneumonia. The population was predominantly male, Caucasian and non-Hispanic. With the PCT cut-off of 0.25 ng/ml, 2375 (64.8 %) patients had a PCT level <0.25 ng/mL, and 1290 (35.2 %) had PCT ≥0.25 ng/ml. While when the PCT cut off of 0.50 ng/ml was used we observed 2934 (80.05 %) patients with a PCT <0.50 ng/ml while 731(19.94 %) patients had a PCT ≥0.50 ng/ml. Patients with higher PCT levels exhibited significantly higher rates of bacterial infections (0.25 ng/ml cut-off: 4.2 % vs 7.9 %; 0.50 ng/ml cut-off: 4.6 % vs 9.2 %). Antibiotics were used in 66.0 % of the cohort. Regardless of the PCT cutoffs, the antibiotics group showed increased hospital length of stay (LOS), intensive care unit (ICU) admission rate, and mortality. However, early de-escalation (<24 h) of antibiotics correlated with reduced hospital LOS, ICU LOS, and mortality. These results were consistent even after adjusting for confounders. CONCLUSION Our study shows a substantial number of COVID-19 pneumonia patients received antibiotics despite a low incidence of bacterial infections. Therefore, antibiotics use in COVID pneumonia patients with PCT <0.5 in the absence of clinical evidence of bacterial infection has no beneficial effect.
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Affiliation(s)
- Lekhya Raavi
- Department of Critical Care Medicine, Mayo Clinic in Florida, USA
| | - Shahin Isha
- Department of Critical Care Medicine, Mayo Clinic in Florida, USA
| | - Sadhana Jonna
- Department of Critical Care Medicine, Mayo Clinic in Florida, USA
| | - Emily C Craver
- Department of Quantitative Health Sciences, Mayo Clinic in Florida, USA
| | | | - Anna Jenkins
- Department of Critical Care Medicine, Mayo Clinic in Florida, USA
| | - Abby J Hanson
- Department of Critical Care Medicine, Mayo Clinic in Florida, USA
| | | | | | - Aysun Tekin
- Department of Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Vikas Bansal
- Department of Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Sean M Caples
- Division of Pulmonary and Critical Care, Mayo Clinic, Rochester, Minnesota, USA
| | - Syed Anjum Khan
- Department of Critical Care Medicine, Mayo Clinic Health System in Mankato, USA
| | - Nitesh K Jain
- Department of Critical Care Medicine, Mayo Clinic Health System in Mankato, USA
| | - Abigail T LaNou
- Emergency Medicine and Critical Care, Mayo Clinic Health System, Eau Claire, WI, USA
| | - Rahul Kashyap
- Department of Anesthesia and Critical Care Medicine, Mayo Clinic Rochester, Minnesota, USA
| | | | - Bhavesh M Patel
- Department of Critical Care Medicine, Mayo Clinic, Arizona, USA
| | | | - Carla P Venegas
- Department of Critical Care Medicine, Mayo Clinic in Florida, USA
| | - Anna B Shapiro
- Department of Critical Care Medicine, Mayo Clinic in Florida, USA
| | | | - Sanjay Chaudhary
- Department of Critical Care Medicine, Mayo Clinic in Florida, USA
| | - Sean P Kiley
- Department of Critical Care Medicine, Mayo Clinic in Florida, USA
| | - Young M Erben
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, FL, USA
| | | | - Neal M Patel
- Department of Critical Care Medicine, Mayo Clinic in Florida, USA
| | - Pramod K Guru
- Department of Critical Care Medicine, Mayo Clinic in Florida, USA
| | | | - Archana Roy
- Division of Hospital Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
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Webb EJD, Howdon D, Bestwick R, King N, Sandoe JAT, Euden J, Grozeva D, West R, Howard P, Powell N, Albur M, Bond S, Brookes-Howell L, Dark P, Hellyer T, Llewelyn M, McCullagh IJ, Ogden M, Pallmann P, Parsons H, Partridge D, Shaw D, Szakmany T, Todd S, Thomas-Jones E, Carrol ED, Shinkins B. The cost-effectiveness of procalcitonin for guiding antibiotic prescribing in individuals hospitalized with COVID-19: part of the PEACH study. J Antimicrob Chemother 2024; 79:1831-1842. [PMID: 38842487 PMCID: PMC11290882 DOI: 10.1093/jac/dkae167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 05/02/2024] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND Many hospitals introduced procalcitonin (PCT) testing to help diagnose bacterial coinfection in individuals with COVID-19, and guide antibiotic decision-making during the COVID-19 pandemic in the UK. OBJECTIVES Evaluating cost-effectiveness of using PCT to guide antibiotic decisions in individuals hospitalized with COVID-19, as part of a wider research programme. METHODS Retrospective individual-level data on patients hospitalized with COVID-19 were collected from 11 NHS acute hospital Trusts and Health Boards from England and Wales, which varied in their use of baseline PCT testing during the first COVID-19 pandemic wave. A matched analysis (part of a wider analysis reported elsewhere) created groups of patients whose PCT was/was not tested at baseline. A model was created with combined decision tree/Markov phases, parameterized with quality-of-life/unit cost estimates from the literature, and used to estimate costs and quality-adjusted life years (QALYs). Cost-effectiveness was judged at a £20 000/QALY threshold. Uncertainty was characterized using bootstrapping. RESULTS People who had baseline PCT testing had shorter general ward/ICU stays and spent less time on antibiotics, though with overlap between the groups' 95% CIs. Those with baseline PCT testing accrued more QALYs (8.76 versus 8.62) and lower costs (£9830 versus £10 700). The point estimate was baseline PCT testing being dominant over no baseline testing, though with uncertainty: the probability of cost-effectiveness was 0.579 with a 1 year horizon and 0.872 with a lifetime horizon. CONCLUSIONS Using PCT to guide antibiotic therapy in individuals hospitalized with COVID-19 is more likely to be cost-effective than not, albeit with uncertainty.
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Affiliation(s)
- Edward J D Webb
- Leeds Institute for Health Sciences, University of Leeds, Leeds, UK
| | - Daniel Howdon
- Leeds Institute for Health Sciences, University of Leeds, Leeds, UK
| | - Rebecca Bestwick
- Leeds Institute for Health Sciences, University of Leeds, Leeds, UK
| | - Natalie King
- Leeds Institute for Health Sciences, University of Leeds, Leeds, UK
| | - Jonathan A T Sandoe
- Healthcare Associated Infection Group, Leeds Institute of Medical Research, University of Leeds, Leeds, UK
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Joanne Euden
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Detelina Grozeva
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Robert West
- Leeds Institute for Health Sciences, University of Leeds, Leeds, UK
| | - Philip Howard
- Healthcare Associated Infection Group, Leeds Institute of Medical Research, University of Leeds, Leeds, UK
- NHS England North-East & Yorkshire, Leeds, UK
| | - Neil Powell
- Pharmacy Department, Royal Cornwall Hospital, Royal Cornwall Hospitals NHS Foundation Trust, Truro TR1 3LJ, UK
| | - Mahableshwar Albur
- Severn Infectious Sciences, Southmead Hospital, North Bristol NHS Trust, Bristol BS10 5NB, UK
| | - Stuart Bond
- Medicines Optimisation and Pharmacy Services, Pinderfields Hospital, Mid Yorkshire Teaching NHS Trust, Wakefield WF1 4DG, UK
| | - Lucy Brookes-Howell
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Paul Dark
- Division of Immunology, Faculty of Biology, Medicine and Health, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, University of Manchester, Manchester M13 9PL, UK
| | - Thomas Hellyer
- Perioperative and Critical Care Department, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne NE7 7DN, UK
- Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
| | - Martin Llewelyn
- Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton BN1 9PS, UK
- Department of Infection Medicine, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Iain J McCullagh
- Perioperative and Critical Care Department, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne NE7 7DN, UK
- Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
| | - Margaret Ogden
- Public and Patient Involvement Representative, NIHR, London SW1A 2NS, UK
| | - Philip Pallmann
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Helena Parsons
- Department of Microbiology, Laboratory Medicine, Northern General Hospital, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield S5 7AU, UK
| | - David Partridge
- Department of Microbiology, Laboratory Medicine, Northern General Hospital, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield S5 7AU, UK
| | - Dominick Shaw
- Department of Respiratory Sciences, University of Leicester, Leicester, UK
| | - Tamas Szakmany
- Royal Gwent Hospital, Aneurin Bevan University Health Board, Newport, UK
| | - Stacy Todd
- Tropical and Infectious Disease Unit, The Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Emma Thomas-Jones
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Enitan D Carrol
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
| | - Bethany Shinkins
- Leeds Institute for Health Sciences, University of Leeds, Leeds, UK
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
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4
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Henley J, Brookes-Howell L, Euden J, Pallmann P, Llewelyn M, Howard P, Powell N, Dark P, Szakmany T, Hellyer TP, Albur M, Hamilton R, Prestwich G, Ogden M, Maboshe W, Sandoe J, Thomas-Jones E, Carrol E. Developing a model for decision-making around antibiotic prescribing for patients with COVID-19 pneumonia in acute NHS hospitals during the first wave of the COVID-19 pandemic: qualitative results from the Procalcitonin Evaluation of Antibiotic use in COVID-19 Hospitalised patients (PEACH Study). BMJ Open 2023; 13:e077117. [PMID: 38114276 DOI: 10.1136/bmjopen-2023-077117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2023] Open
Abstract
OBJECTIVE To explore and model factors affecting antibiotic prescribing decision-making early in the pandemic. DESIGN Semistructured qualitative interview study. SETTING National Health Service (NHS) trusts/health boards in England and Wales. PARTICIPANTS Clinicians from NHS trusts/health boards in England and Wales. METHOD Individual semistructured interviews were conducted with clinicians in six NHS trusts/health boards in England and Wales as part of the Procalcitonin Evaluation of Antibiotic use in COVID-19 Hospitalised patients study, a wider study that included statistical analysis of procalcitonin (PCT) use in hospitals during the first wave of the pandemic. Thematic analysis was used to identify key factors influencing antibiotic prescribing decisions for patients with COVID-19 pneumonia during the first wave of the pandemic (March to May 2020), including how much influence PCT test results had on these decisions. RESULTS During the first wave of the pandemic, recommendations to prescribe antibiotics for patients with COVID-19 pneumonia were based on concerns about secondary bacterial infections. However, as clinicians gained more experience with COVID-19, they reported increasing confidence in their ability to distinguish between symptoms and signs caused by SARS-CoV-2 viral infection alone, and secondary bacterial infections. Antibiotic prescribing decisions were influenced by factors such as clinician experience, confidence, senior support, situational factors and organisational influences. A decision-making model was developed. CONCLUSION This study provides insight into the decision-making process around antibiotic prescribing for patients with COVID-19 pneumonia during the first wave of the pandemic. The importance of clinician experience and of senior review of decisions as factors in optimising antibiotic stewardship is highlighted. In addition, situational and organisational factors were identified that could be optimised. The model presented in the study can be used as a tool to aid understanding of the complexity of the decision-making process around antibiotic prescribing and planning antimicrobial stewardship support in the context of a pandemic. TRIAL REGISTRATION NUMBER ISRCTN66682918.
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Affiliation(s)
- Josie Henley
- School of Social Sciences, Cardiff University, Cardiff, UK
| | | | - Joanne Euden
- College of Biomedical and Life Sciences, Cardiff University Centre for Trials Research, Cardiff, UK
| | - Philip Pallmann
- College of Biomedical and Life Sciences, Cardiff University Centre for Trials Research, Cardiff, UK
| | - Martin Llewelyn
- Brighton and Sussex Medical School, University of Sussex and University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Philip Howard
- School of Healthcare, University of Leeds, Leeds, UK
- Pharmacy, Leeds Teaching Hospitals, Leeds, UK
| | - Neil Powell
- Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Paul Dark
- Intensive Care Unit, University of Manchester, Salford, UK
| | - Tamas Szakmany
- Critical Care Directorate, Aneurin Bevan University Health Board, Newport, UK
- Department of Anaesthesia, Intensive Care and Pain Medicine, Division of Population Medicine, Cardiff Univeristy, Cardiff, UK
| | - Thomas P Hellyer
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Ryan Hamilton
- School of Pharmacy, De Montfort University, Leicester, UK
| | | | - Margaret Ogden
- Faculty of Social Sciences, University of Stirling, Stirling, UK
| | | | - Jonathan Sandoe
- Department of Microbiology, The General Infirmary at Leeds, Leeds, UK
- Healthcare Associated Infection Group, Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | | | - Enitan Carrol
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
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