The first 5 years of Helicobacter pylori research-With an emphasis on the United Kingdom

In the 1970s, 1% of the UK population consulted with dyspepsia; fiberoptic gastroscopy allowed biopsy specimens under direct vision enabling systematic histopathology. Steer et al described clusters of flagellated bacteria closely apposed to the gastric epithelium associated with chronic active gastritis. The first UK series of Helicobacter pylori following Marshall's 1983 visit to Worcester confirmed the association of H. pylori with gastritis. UK researchers completed much early helicobacter research as there were many UK campylobacteriologists. Steer and Newell proved the Campylobacter-like organisms grown on culture were the same as those seen in the gastric mucosa using antiserum raised by inoculating rabbits with H. pylori from cultures. Wyatt, Rathbone, and others showed a strong correlation between the number of organisms, type and severity of acute gastritis, immunological response, and bacterial adhesion similar to enteropathogenic E coli. Seroprevalence studies indicated H. pylori increased with age. Histopathologists also showed peptic duodenitis was in effect "gastritis in the duodenum" caused by H. pylori, unifying its role in the pathogenesis of both gastritis and duodenal ulceration. These bacteria were initially called Campylobacter pyloridis and then C. pylori. However, electron microscopy suggested that the bacteria were not campylobacters, and this was supported by differences in fatty acid and polyacrylamide electrophoresis profiles. In-vitro tests indicated that H. pylori was susceptible to penicillins, erythromycin, and quinolones, but not trimethoprim or cefsulodin allowing development of selective media for culture. Monotherapy with erythromycin ethylsuccinate was ineffective, and patients treated with bismuth subsalicylate initially responded with clearance of H. pylori and the associated gastritis, but then many relapsed. Thus, pharmacokinetic and treatment studies were important to direct suitable dual and triple treatments. Work optimized serology, and the rapid biopsy urease and urea breath tests. The link between H.pylori and gastric cancer was established in large seroprevalence studies, and H. pylori test and treat for dyspepsia became routine.

Empowering Patients to Self-Manage Common Infections: Qualitative Study Informing the Development of an Evidence-Based Patient Information Leaflet

Common self-limiting infections can be self-managed by patients, potentially reducing consultations and unnecessary antibiotic use. This qualitative study informed by the Theoretical Domains Framework (TDF) aimed to explore healthcare professionals' (HCPs) and patients' needs on provision of self-care and safety-netting advice for common infections. Twenty-seven patients and seven HCPs participated in semi-structured focus groups (FGs) and interviews. An information leaflet was iteratively developed and reviewed by participants in interviews and FGs, and an additional 5 HCPs, and 25 patients (identifying from minority ethnic groups) via online questionnaires. Qualitative data were analysed thematically, double-coded, and mapped to the TDF. Participants required information on symptom duration, safety netting, self-care, and antibiotics. Patients felt confident to self-care and were averse to consulting with HCPs unnecessarily but struggled to assess symptom severity. Patients reported seeking help for children or elderly dependents earlier. HCPs' concerns included patients' attitudes and a lack of available monitoring of advice given to patients. Participants believed community pharmacy should be the first place that patients seek advice on common infections. The patient information leaflet on common infections should be used in primary care and community pharmacy to support patients to self-manage symptoms and determine when further help is required.

How did a Quality Premium financial incentive influence antibiotic prescribing in primary care? Views of Clinical Commissioning Group and general practice professionals

BACKGROUND

The Quality Premium (QP) was introduced for Clinical Commissioning Groups (CCGs) in England to optimize antibiotic prescribing, but it remains unclear how it was implemented.

OBJECTIVES

To understand responses to the QP and how it was perceived to influence antibiotic prescribing.

METHODS

Semi-structured telephone interviews were conducted with 22 CCG and 19 general practice professionals. Interviews were analysed thematically.

RESULTS

The findings were organized into four categories. (i) Communication: this was perceived as unstructured and infrequent, and CCG professionals were unsure whether they received QP funding. (ii) Implementation: this was influenced by available local resources and competing priorities, with multifaceted and tailored strategies seen as most helpful for engaging general practices. Many antimicrobial stewardship (AMS) strategies were implemented independently from the QP, motivated by quality improvement. (iii) Mechanisms: the QP raised the priority of AMS nationally and locally, and provided prescribing targets to aim for and benchmark against, but money was not seen as reinvested into AMS. (iv) Impact and sustainability: the QP was perceived as successful, but targets were considered challenging for a minority of CCGs and practices due to contextual factors (e.g. deprivation, understaffing). CCG professionals were concerned with potential discontinuation of the QP and prescribing rates levelling off.

CONCLUSIONS

CCG and practice professionals expressed positive views of the QP and associated prescribing targets and feedback. The QP helped influence change mainly by raising the priority of AMS and defining change targets rather than providing additional funding. To maximize impact, behavioural mechanisms of financial incentives should be considered pre-implementation.

Knowledge and attitudes of adolescents towards the human microbiome and antibiotic resistance: a qualitative study

Background

Antibiotic and dietary behaviour affect the human microbiome and influence antibiotic resistance development. Adolescents are a key demographic for influencing knowledge and behaviour change.

Objectives

To explore adolescents' knowledge and attitudes towards the microbiome and antibiotic resistance, and the capability, motivation and opportunity for educators to integrate microbiome teaching in schools.

Methods

Qualitative study informed by the Theoretical Domains Framework (TDF) and COM-B model. Six educational establishments were purposively selected by rural/city and socioeconomic status, within Gloucestershire, South West England in 2019. Forty 14-18-year olds participated in focus groups, and eight science or health educators participated in interviews. Data were analysed thematically, double-coded and mapped to the TDF/COM-B.

Results

Adolescents were aware of 'good microbes' in the body but lacked deeper knowledge. Adolescents' knowledge of, and intentions to use, antibiotics appropriately differed by their levels of scientific study. Adolescents lacked knowledge on the consequences of diet on the microbiome, and therefore lacked capability and motivation to change behaviour. Educators felt capable and motivated to teach microbiome topics but lacked opportunity though absence of topics in the national curriculum and lack of time to teach additional topics.

Conclusions

A disparity in knowledge of adolescents needs to be addressed through increasing antibiotic and microbiome topics in the national curriculum. Public antibiotic campaigns could include communication about the microbiome to increase awareness. Educational resources could motivate adolescents and improve their knowledge, skills and opportunity to improve diet and antibiotic use; so, supporting the UK antimicrobial resistance (AMR) national action plan.

Optimising antimicrobial stewardship interventions in English primary care: a behavioural analysis of qualitative and intervention studies

OBJECTIVE

While various interventions have helped reduce antibiotic prescribing, further gains can be made. This study aimed to identify ways to optimise antimicrobial stewardship (AMS) interventions by assessing the extent to which important influences on antibiotic prescribing are addressed (or not) by behavioural content of AMS interventions.

SETTINGS

English primary care.

INTERVENTIONS

AMS interventions targeting healthcare professionals' antibiotic prescribing for respiratory tract infections.

METHODS

We conducted two rapid reviews. The first included qualitative studies with healthcare professionals on self-reported influences on antibiotic prescribing. The influences were inductively coded and categorised using the Theoretical Domains Framework (TDF). Prespecified criteria were used to identify key TDF domains. The second review included studies of AMS interventions. Data on effectiveness were extracted. Components of effective interventions were extracted and coded using the TDF, Behaviour Change Wheel and Behaviour Change Techniques (BCTs) taxonomy. Using prespecified matrices, we assessed the extent to which BCTs and intervention functions addressed the key TDF domains of influences on prescribing.

RESULTS

We identified 13 qualitative studies, 41 types of influences on antibiotic prescribing and 6 key TDF domains of influences: 'beliefs about consequences', 'social influences', 'skills', 'environmental context and resources', 'intentions' and 'emotions'. We identified 17 research-tested AMS interventions; nine of them effective and four nationally implemented. Interventions addressed all six key TDF domains of influences. Four of these six key TDF domains were addressed by 50%-67% BCTs that were theoretically congruent with these domains, whereas TDF domain 'skills' was addressed by 24% of congruent BCTs and 'emotions' by none.

CONCLUSIONS

Further improvement of antibiotic prescribing could be facilitated by: (1) national implementation of effective research-tested AMS interventions (eg, electronic decision support tools, training in interactive use of leaflets, point-of-care testing); (2) targeting important, less-addressed TDF domains (eg, 'skills', 'emotions'); (3) using relevant, under-used BCTs to target key TDF domains (eg, 'forming/reversing habits', 'reducing negative emotions', 'social support'). These could be incorporated into existing, or developed as new, AMS interventions.

Feasibility of a community pharmacy antimicrobial stewardship intervention (PAMSI): an innovative approach to improve patients' understanding of their antibiotics

BACKGROUND

Community pharmacy staff have an opportunity to play a pivotal role in antimicrobial stewardship (AMS) due to their expertise in medicines and accessibility to patients.

OBJECTIVES

To develop and test the feasibility of a pharmacy AMS intervention (PAMSI) to increase community pharmacy staff's capability, opportunity and motivation to check antibiotic appropriateness and provide self-care and adherence advice when dispensing antibiotics.

METHODS

The PAMSI was centred around an Antibiotic Checklist, completed by patients and pharmacy staff, to facilitate personalized advice to the patient, based on their reported knowledge. An educational webinar for staff and patient-facing materials were also developed. Staff and patients completing Antibiotic Checklists were invited to provide feedback via questionnaires.

RESULTS

In February 2019, 12 community pharmacies in England trialled the intervention. Forty-three pharmacy staff evaluated the educational webinar and reported increases in their understanding, confidence, commitment and intention to use the tools provided to give adherence and self-care advice. Over 4 weeks, 931 Antibiotic Checklists were completed. Staff reported being more focused on giving advice and able to address patients' knowledge gaps (mainly: likely symptom duration; alcohol and food consumption advice; possible side effects from antibiotics; returning unused antibiotics to the pharmacy), resulting in increased self-reported effective and meaningful conversations.

CONCLUSIONS

Implementation of a PAMSI is feasible and effectively promotes AMS. Pharmacy staff and commissioners should consider this within their AMS plans. An optional digital format of the Antibiotic Checklist should be explored, for patients who are not collecting their antibiotic prescriptions themselves, and to save printing costs.

Preventing and Managing Urinary Tract Infections: Enhancing the Role of Community Pharmacists-A Mixed Methods Study

BACKGROUND

Community pharmacists are involved in antimicrobial stewardship through self-care advice and delivering medications for uncomplicated infections.

OBJECTIVES

This mixed methods study aimed to identify opportunities to enhance the role of community pharmacists in the management of service users with suspected or confirmed urinary tract infection (UTI).

METHODS

Data collection was through a service user survey (n = 51) and pharmacist surveys and semi-structured interviews before (16 interviews, 22 questionnaires) and after (15 interviews, 16 questionnaires) trialing UTI leaflets designed to be shared with service users. Data were analysed inductively using thematic analysis and descriptive tabulation of quantitative data.

RESULTS

Twenty-five percent (n = 13/51) of service users with urinary symptoms sought help from a pharmacist first and 65% (n = 33/51) were comfortable discussing their urinary symptoms with a pharmacist in a private space. Community pharmacists were confident as the first professional contact for service users with uncomplicated UTI (n = 13/16, 81%), but indicated the lack of a specific patient referral pathway (n = 16/16, 100%), the need for additional funding and staff (n = 10/16, 62%), and the importance of developing prescription options for pharmacists (5/16, 31%). All community pharmacists reported playing a daily role in controlling antimicrobial resistance by educating service users about viral and bacterial infections and promoting a healthy lifestyle. Enhancing their role will need greater integrated working with general practices and more prescribers based in community pharmacy.

CONCLUSION

This study suggests that community pharmacists could play a greater role in the management of uncomplicated UTI. The current reconfiguration of primary care in England with primary care networks and integrated care systems could provide a real opportunity for this collaborative working with potential learning for international initiatives.

Optimising Interventions for Catheter-Associated Urinary Tract Infections (CAUTI) in Primary, Secondary and Care Home Settings

Catheter-associated urinary tract infections (CAUTI) are common yet preventable. Healthcare professional behaviours, such as reducing unnecessary catheter use, are key for preventing CAUTI. Previous research has focused on identifying gaps in the national response to CAUTI in multiple settings in England. This study aimed to identify how national interventions could be optimised. We conducted a multi-method study comprising: a rapid review of research on interventions to reduce CAUTI; a behavioural analysis of effective research interventions compared to national interventions; and a stakeholder focus group and survey to identify the most promising options for optimising interventions. We identified 37 effective research interventions, mostly conducted in United States secondary care. A behavioural analysis of these interventions identified 39 intervention components as possible ways to optimise national interventions. Seven intervention components were prioritised by stakeholders. These included: checklists for discharge/admission to wards; information for patients and relatives about the pros/cons of catheters; setting and profession specific guidelines; standardised nationwide computer-based documentation; promotion of alternatives to catheter use; CAUTI champions; and bladder scanners. By combining research evidence, behavioural analysis and stakeholder feedback, we identified how national interventions to reduce CAUTI could be improved. The seven prioritised components should be considered for future implementation.

What antimicrobial stewardship strategies do NHS commissioning organizations implement in primary care in England?

Objectives

To identify and explore strategies that English NHS commissioning organizations implemented to improve antimicrobial stewardship (AMS) within primary care.

Methods

Questionnaire sent to the medicines management teams (MMTs) of all 209 clinical commissioning groups (CCGs) in England, in 2017.

Results

A total of 89% (187/209) of all English CCGs responded to the questionnaire; 74% of responding CCGs (123/167) had a prescribing incentive/engagement scheme, with MMTs representing 88% (90/102) considering incentive schemes successful or very successful for prioritizing AMS in primary care, especially when linked to prescribing NHS Quality Premium indicators. AMS audits were considered successful or very successful by 91% (126/138) of responding CCGs, as they identify reasons for inappropriate prescribing and opportunities for future improvement. All responding MMTs (169/169 CCGs) reported feeding back local/national antimicrobial prescribing data to the general practices they commission, 85% (142/168) to their CCG/Commissioning Support Unit (CSU) board and only 33% (56/169) to out-of-hours services. Benchmarking prescribing data was reported as a powerful tool to engage practices, facilitating an element of competition and peer pressure.

Conclusions

National antimicrobial resistance improvement schemes, in particular the NHS England Quality Premium, have influenced CCG improvement priorities. Most CCGs now report successful improvement strategies including the use of both local and national antibiotic prescribing data to motivate improvements; these should be continued and extended to out-of-hours providers. As local audit data have helped to identify reasons for inappropriate prescribing and inform improvement planning, all organizations should adopt this strategy and include it in local quality improvement schemes, ensuring performance reporting to organizational board level.

Evaluation of an Educational Health Website on Infections and Antibiotics in England: Mixed Methods, User-Centered Approach

Background

e-Bug, an educational health website for teachers and students, aims to help control antibiotic resistance by educating young people about microbes, hygiene, and antibiotic resistance, reducing the incidence of infection and, therefore, the need for antibiotics. The teachers’ section of the e-Bug website has not been evaluated since it was launched in 2009, and worldwide page views have been steadily decreasing since 2013.

Objective

This study aimed to apply GoodWeb, a comprehensive framework utilizing methodologies and attributes that are relevant to the digital era, to evaluate and suggest improvements to the e-Bug website.

Methods

Electronic questionnaires and face-to-face completion of task scenarios were used to assess content, ease of use, interactivity, technical adequacy, appearance, effectiveness, efficiency, and learnability of the teachers’ section of the e-Bug website.

Results

A total of 106 teachers evaluated the e-Bug website; 97.1% (103/106) of them reported that they would use e-Bug, and 98.1% (104/106) of them reported that they would recommend it to others. Participants thought that there was a niche for e-Bug because of the way the resources fit into the national curriculum. Suggestions for improvements included changing the menu indication by highlighting the current page or deactivating links, improving home page indication, and providing a preview of resources when hovering the mouse over hyperlinks. Additional features requested by users included a search function and access to training opportunities.

Conclusions

This paper reports that the GoodWeb framework was successfully applied to evaluate the e-Bug website, and therefore, it could be used to guide future website evaluations in other fields. Results from this study will be used to appraise the current quality and inform any future changes, modifications, and additions to e-Bug.

International promotion of e-Bug, an infection prevention and control educational intervention: survey of partners across 14 countries

BACKGROUND

Antimicrobial resistance (AMR) is a global threat to public health. e-Bug is an educational resource developed and promoted by a network of international partners. e-Bug seeks to reduce the spread of infection and use of antimicrobials in young people and the community, so helping to control AMR. This study aimed to explore how e-Bug is promoted by international partners and observe barriers to promotion, including the extent of education about antibiotics in schools.

METHODS

A total of 29 e-Bug partners were invited to complete online questionnaires on (i) methods they use to promote e-Bug; and (ii) antibiotic topics covered in the national curriculum in their countries.

RESULTS

Fourteen and 15 of 29 e-Bug partners across Europe and Palestine completed the promotional activities and curriculum questionnaires respectively. The most frequently reported methods of promotion included endorsement and collaboration with government and non-government sectors and involvement in national and global health awareness campaigns. Barriers to promotion included a lack of time and funding. The curriculum survey data showed variation in antibiotic education across Europe and Palestine, lack of antibiotic education for children under 11 years of age and little change in antibiotic topics included in the curriculum since 2006.

CONCLUSIONS

Future and existing e-Bug partners should be encouraged to follow promotional activities reported in this paper, including ministry endorsement, educator training, international campaigns and youth programmes. We encourage all countries to increase antibiotic topics in the school curriculum across all ages.

Public understanding and use of antibiotics in England: findings from a household survey in 2017

OBJECTIVES

To describe public understanding and use of antibiotics.

DESIGN

Ipsos MORI Capibus survey of randomly-selected households.

SETTING

England, January-April 2017.

PARTICIPANTS

2283 adults (≥15 years) including 777 parents of children <5 years old.

DATA COLLECTION AND ANALYSIS

The main survey was undertaken in January 2017 (n=1691); data from an additional sample of parents were collected in April 2017 (n=592). Analyses were weighted to obtain estimates representative of the population.

MAIN OUTCOME MEASURES

Responses to questions about antibiotics (awareness and perceptions), recent illness (expectations and experience), delayed and leftover antibiotics, and child illness stratified by demographic and socioeconomic characteristics.

RESULTS

Most respondents (83% (1404/1691)) recognised that antibiotics kill bacteria/treat bacterial infections, but a sizeable minority (35% (592/1691)) thought that antibiotics kill viruses/treat viral infections. Overall levels of understanding have not changed substantially since similar surveys in 2003 and 2008/2009. One sixth of respondents who were prescribed antibiotics reported having leftovers (14% (64/498)) and 33% (22/64) kept these for possible future use. 1.3% of all respondents (23/1691) reported taking left-over antibiotics in the past year and 1.6% (26/1691) reported taking antibiotics obtained without a prescription. Higher social grade and educational qualifications were strongly positively associated with antibiotic knowledge; youngest (15-24 years), oldest (65 +years) and black, Asian and minority ethnic adults were less knowledgeable. Among 1319 respondents who had an infection or antibiotics within the past year, 43% (568/1319) said that they had not received any advice or information about antibiotics.

CONCLUSIONS

Despite many campaigns, public understanding of antibiotics in England continues to combine correct basic knowledge held by most people with less prevalent but persistent and potentially harmful misunderstandings. These could be addressed through active provision of advice and information during primary and secondary care consultations and more effective public health interventions.

A Comprehensive Framework to Evaluate Websites: Literature Review and Development of GoodWeb

BACKGROUND

Attention is turning toward increasing the quality of websites and quality evaluation to attract new users and retain existing users.

OBJECTIVE

This scoping study aimed to review and define existing worldwide methodologies and techniques to evaluate websites and provide a framework of appropriate website attributes that could be applied to any future website evaluations.

METHODS

We systematically searched electronic databases and gray literature for studies of website evaluation. The results were exported to EndNote software, duplicates were removed, and eligible studies were identified. The results have been presented in narrative form.

RESULTS

A total of 69 studies met the inclusion criteria. The extracted data included type of website, aim or purpose of the study, study populations (users and experts), sample size, setting (controlled environment and remotely assessed), website attributes evaluated, process of methodology, and process of analysis. Methods of evaluation varied and included questionnaires, observed website browsing, interviews or focus groups, and Web usage analysis. Evaluations using both users and experts and controlled and remote settings are represented. Website attributes that were examined included usability or ease of use, content, design criteria, functionality, appearance, interactivity, satisfaction, and loyalty. Website evaluation methods should be tailored to the needs of specific websites and individual aims of evaluations. GoodWeb, a website evaluation guide, has been presented with a case scenario.

CONCLUSIONS

This scoping study supports the open debate of defining the quality of websites, and there are numerous approaches and models to evaluate it. However, as this study provides a framework of the existing literature of website evaluation, it presents a guide of options for evaluating websites, including which attributes to analyze and options for appropriate methods.

CTX-M ESBL-producing Enterobacteriaceae: estimated prevalence in adults in England in 2014

Background

ESBL-producing Enterobacteriaceae (ESBLPE) are increasing in prevalence worldwide and are more difficult to treat than non-ESBLPE. Their prevalence in the UK general population is unknown, as the only previous UK ESBLPE faecal colonization study involved patients with diarrhoea.

Objectives

To estimate the prevalence of CTX-M ESBLPE faecal colonization in the general adult population of England in 2014, and investigate risk factors.

Methods

A stratified random sample of 58 337 registered patients from 16 general practices within four areas of England were invited to participate by returning faeces specimens and self-completed questionnaires. Specimens were tested for ESBLPE and carbapenemase-producing Enterobacteriaceae (CPE).

Results

2430 individuals participated (4% of those invited). The estimated prevalence of colonization with CTX-M ESBLPE in England was 7.3% (95% CI 5.6%–9.4%) (Shropshire 774 participants, 4.9% colonization; Southampton City 740 participants, 9.2%; Newham 612 participants, 12.7%; Heart of Birmingham 234 individuals, 16.0%) and was particularly high in: those born in Afghanistan (10 participants, 60.0% colonization, 95% CI 29.7%–84.2%); those born on the Indian subcontinent (India, Pakistan, Bangladesh or Sri Lanka) (259 participants, 25.0% colonization, 95% CI 18.5%–32.9%); travellers to South Asia (India, Pakistan, Bangladesh, Sri Lanka or Nepal) in the last year (140 participants, 38.5% colonization, 95% CI 27.8%–50.5%); and healthcare domestics (8 participants, unweighted 37.5% colonization, 95% CI 8.5%–75.5%). Risk factors identified included: being born in the Indian subcontinent (aOR 5.4, 95% CI 3.0–9.7); travel to South Asia (aOR 2.9, 95% CI 1.8–4.8) or to Africa, China, South or Central America, South East or Pacific Asia or Afghanistan (aOR 2.6, 95% CI 1.7–4.1) in the last year; and working as a healthcare domestic (aOR 6.2, 95% CI 1.3–31). None of the 48 participants who took co-amoxiclav in the last year was colonized with CTX-M ESBLPE. bla_CTX-M-15 accounted for 66% of CTX-M ESBLPE positives. 0.1% (two participants) were colonized with CPE.

Conclusions

CTX-M ESBLPE are established in the general population in England and prevalence is particularly high in people from certain countries of birth or with recent travel. We recommend that these findings be taken into account in guidance on the empirical management of patients presenting with a likely Enterobacteriaceae infection.

Treatment of infections caused by multidrug-resistant Gram-negative bacteria: report of the British Society for Antimicrobial Chemotherapy/Healthcare Infection Society/British Infection Association Joint Working Party

The Working Party makes more than 100 tabulated recommendations in antimicrobial prescribing for the treatment of infections caused by multidrug-resistant (MDR) Gram-negative bacteria (GNB) and suggest further research, and algorithms for hospital and community antimicrobial usage in urinary infection. The international definition of MDR is complex, unsatisfactory and hinders the setting and monitoring of improvement programmes. We give a new definition of multiresistance. The background information on the mechanisms, global spread and UK prevalence of antibiotic prescribing and resistance has been systematically reviewed. The treatment options available in hospitals using intravenous antibiotics and in primary care using oral agents have been reviewed, ending with a consideration of antibiotic stewardship and recommendations. The guidance has been derived from current peer-reviewed publications and expert opinion with open consultation. Methods for systematic review were NICE compliant and in accordance with the SIGN 50 Handbook; critical appraisal was applied using AGREE II. Published guidelines were used as part of the evidence base and to support expert consensus. The guidance includes recommendations for stakeholders (including prescribers) and antibiotic-specific recommendations. The clinical efficacy of different agents is critically reviewed. We found there are very few good-quality comparative randomized clinical trials to support treatment regimens, particularly for licensed older agents. Susceptibility testing of MDR GNB causing infection to guide treatment needs critical enhancements. Meropenem- or imipenem-resistant Enterobacteriaceae should have their carbapenem MICs tested urgently, and any carbapenemase class should be identified: mandatory reporting of these isolates from all anatomical sites and specimens would improve risk assessments. Broth microdilution methods should be adopted for colistin susceptibility testing. Antimicrobial stewardship programmes should be instituted in all care settings, based on resistance rates and audit of compliance with guidelines, but should be augmented by improved surveillance of outcome in Gram-negative bacteraemia, and feedback to prescribers. Local and national surveillance of antibiotic use, resistance and outcomes should be supported and antibiotic prescribing guidelines should be informed by these data. The diagnosis and treatment of both presumptive and confirmed cases of infection by GNB should be improved. This guidance, with infection control to arrest increases in MDR, should be used to improve the outcome of infections with such strains. Anticipated users include medical, scientific, nursing, antimicrobial pharmacy and paramedical staff where they can be adapted for local use.

Qualitative study using interviews and focus groups to explore the current and potential for antimicrobial stewardship in community pharmacy informed by the Theoretical Domains Framework

OBJECTIVES

Community pharmacists and their staff have the potential to contribute to antimicrobial stewardship (AMS). However, their barriers and opportunities are not well understood. The aim was to investigate the experiences and perceptions of community pharmacists and their teams around AMS to inform intervention development.

DESIGN

Interviews and focus groups were used to explore the views of pharmacists, pharmacy staff, general practitioners (GPs), members of pharmacy organisations and commissioners. The questioning schedule was developed using the Theoretical Domains Framework which helped inform recommendations to facilitate AMS in community pharmacy.

RESULTS

8 GPs, 28 pharmacists, 13 pharmacy staff, 6 representatives from pharmacy organisations in England and Wales, and 2 local stakeholders participated.Knowledge and skills both facilitated or hindered provision of self-care and compliance advice by different grades of pharmacy staff. Some staff were not aware of the impact of giving self-care and compliance advice to help control antimicrobial resistance (AMR). The pharmacy environment created barriers to AMS; this included lack of time of well-qualified staff leading to misinformation from underskilled staff to patients about the need for antibiotics or the need to visit the GP, this was exacerbated by lack of space. AMS activities were limited by absent diagnoses on antibiotic prescriptions.Several pharmacy staff felt that undertaking patient examinations, questioning the rationale for antibiotic prescriptions and performing audits would allow them to provide more tailored AMS advice.

CONCLUSIONS

Interventions are required to overcome a lack of qualified staff, time and space to give patients AMS advice. Staff need to understand how self-care and antibiotic compliance advice can help control AMR. A multifaceted educational intervention including information for staff with feedback about the advice given may help. Indication for a prescription would enable pharmacists to provide more targeted antibiotic advice. Commissioners should consider the pharmacists' role in examining patients, and giving advice about antibiotic prescriptions.

An evaluation of the TARGET (Treat Antibiotics Responsibly; Guidance, Education, Tools) Antibiotics Toolkit to improve antimicrobial stewardship in primary care-is it fit for purpose?

BACKGROUND

The TARGET (Treat Antibiotics Responsibly; Guidance, Education, Tools) Antibiotics Toolkit aims to improve antimicrobial prescribing in primary care through guidance, interactive workshops with action planning, patient facing educational and audit materials.

OBJECTIVE

To explore GPs', nurses' and other stakeholders' views of TARGET.

DESIGN

Mixed methods.

METHOD

In 2014, 40 UK GP staff and 13 stakeholders participated in interviews or focus groups. We analysed data using a thematic framework and normalization process theory (NPT).

RESULTS

Two hundred and sixty-nine workshop participants completed evaluation forms, and 40 GP staff, 4 trainers and 9 relevant stakeholders participated in interviews (29) or focus groups (24). GP staffs were aware of the issues around antimicrobial resistance (AMR) and how it related to their prescribing. Most participants stated that TARGET as a whole was useful. Participants suggested the workshop needed less background on AMR, be centred around clinical cases and allow more action planning time. Participants particularly valued comparison of their practice antibiotic prescribing with others and the TARGET Treating Your Infection leaflet. The leaflet needed greater accessibility via GP computer systems. Due to time, cost, accessibility and competing priorities, many GP staff had not fully utilized all resources, especially the audit and educational materials.

CONCLUSIONS

We found evidence that the workshop is likely to be more acceptable and engaging if based around clinical scenarios, with less on AMR and more time on action planning. Greater promotion of TARGET, through Clinical Commissioning Group's (CCG's) and professional bodies, may improve uptake. Patient facing resources should be made accessible through computer shortcuts built into general practice software.

A mixed-method evaluation of peer-education workshops for school-aged children to teach about antibiotics, microbes and hygiene

Background

Delivering health topics in schools through peer education is known to be beneficial for all students involved. In this study, we have evaluated a peer-education workshop that aims to educate primary and secondary school students on hygiene, the spread of infection and antibiotics.

Methods

Four schools in south-west England, in a range of localities, took part in peer-education workshops, with students completing before, after and knowledge-retention questionnaires. Mixed-effect logistic regression and mixed-effect linear regression were used to analyse the data. Data were analysed by topic, region and peer/non-peer-educator status. Qualitative interviews and focus groups with students and educators were conducted to assess changes in participants' skills, confidence and behaviour.

Results

Qualitative data indicated improvements in peer-educator skills and behaviour, including confidence, team-working and communication. There was a significant improvement in knowledge for all topics covered in the intervention, although this varied by region. In the antibiotics topic, peer-educators' knowledge increased in the retention questionnaire, whereas non-peer-educators' knowledge decreased. Knowledge declined in the retention questionnaires for the other topics, although this was mostly not significant.

Conclusions

This study indicates that peer education is an effective way to educate young people on important topics around health and hygiene, and to concurrently improve communication skills. Its use should be encouraged across schools to help in the implementation of the National Institute for Health and Care Excellence (NICE) guidance that recommends children are taught in an age-appropriate manner about hygiene and antibiotics.

Animations designed to raise patient awareness of prudent antibiotic use: patient recall of key messages and their immediate effect on patient attitude

OBJECTIVES

This study aimed to determine if patients recalled key messages from antibiotic animations shown on digital displays in General Practice waiting rooms, and if watching them changed patients' immediate intentions to consult their GP for upper respiratory tract infections, seek antibiotics and self-care.

RESULTS

The pre intervention focus group found the animations intergenerational, informative and educational. 3119 patients were observed in 3 GP practices during project team visits; 145 (4.6%) were observed watching the animations; 132 (91%) remembered seeing them; the key messages were retained by 47-55% of patients. Significant positive differences were observed for questions related to intended antibiotic related behaviours.

Exploring why a complex intervention piloted in general practices did not result in an increase in chlamydia screening and diagnosis: a qualitative evaluation using the fidelity of implementation model

BACKGROUND

Chlamydia trachomatis (chlamydia) is the most commonly diagnosed sexually transmitted infection (STI) in England; approximately 70% of diagnoses are in sexually active young adults aged under 25. To facilitate opportunistic chlamydia screening in general practice, a complex intervention, based on a previously successful Chlamydia Intervention Randomised Trial (CIRT), was piloted in England. The modified intervention (3Cs and HIV) aimed to encourage general practice staff to routinely offer chlamydia testing to all 15-24 year olds regardless of the type of consultation. However, when the 3Cs (chlamydia screening, signposting to contraceptive services, free condoms) and HIV was offered to a large number of general practitioner (GP) surgeries across England, chlamydia screening was not significantly increased. This qualitative evaluation addresses the following aims: a) Explore why the modified intervention did not increase screening across all general practices. b) Suggest recommendations for future intervention implementation.

METHODS

Phone interviews were carried out with 26 practice staff, at least 5 months after their initial educational workshop, exploring their opinions on the workshop and intervention implementation in the real world setting. Interview transcripts were thematically analysed and further examined using the fidelity of implementation model.

RESULTS

Participants who attended had a positive attitude towards the workshops, but attendee numbers were low. Often, the intervention content, as detailed in the educational workshops, was not adhered to: practice staff were unaware of any on-going trainer support; computer prompts were only added to the female contraception template; patients were not encouraged to complete the test immediately; complete chlamydia kits were not always readily available to the clinicians; and videos and posters were not utilised. Staff reported that financial incentives, themselves, were not a motivator; competing priorities and time were identified as major barriers.

CONCLUSION

Not adhering to the exact intervention model may explain the lack of significant increases in chlamydia screening. To increase fidelity of implementation outside of Randomised Controlled Trial (RCT) conditions, and consequently, improve likelihood of increased screening, future public health interventions in general practices need to have: more specific action planning within the educational workshop; computer prompts added to systems and used; all staff attending the workshop; and on-going practice staff support with feedback of progress on screening and diagnosis rates fed back to all staff.

School Nurses' perspectives on the role of the school nurse in health education and health promotion in England: a qualitative study

Background

The role of the school nurse is complex with many possible elements identified by previous research. The aim of this study is to understand perceptions of the role of the school nurse in order to support school nurses in the delivery of health education.

Methods

The study used an inductive, qualitative research design involving semi-structured interviews and focus groups. Participants were recruited from four NHS trusts across England and final sample size was thirty one school nurses. Three focus groups and two interviews took place in person, and three interviews were over the phone. Data was thematically analysed.

Results

School nurses described six main themes. Four themes directly related to the school nurse role: the main roles of a school nurse, school nurses' role in health education, prioritisation of workload and activities, and community work. A further two other themes related to the delivery of health education: the school nursing system and educational resources.

Conclusions

The role of the school nurse in England is very diverse and the school nurse role in health education is primarily to advise and support schools, rather than to directly deliver education. The study identified that tailored public health educational resources are needed to support school nurses.

Service evaluation of an educational intervention to improve sexual health services in primary care implemented using a step-wedge design: analysis of chlamydia testing and diagnosis rate changes

Background

Providing sexual health services in primary care is an essential step towards universal provision. However they are not offered consistently. We conducted a national pilot of an educational intervention to improve staff’s skills and confidence to increase chlamydia testing rates and provide condoms with contraceptive information plus HIV testing according to national guidelines, known as 3Cs&HIV. The effectiveness of the pilot on chlamydia testing and diagnosis rates in general practice was evaluated.

Methods

The pilot was implemented using a step-wedge design over three phases during 2013 and 2014 in England. The intervention combined educational workshops with posters, testing performance feedback and continuous support. Chlamydia testing and diagnosis rates in participating general practices during the control and intervention periods were compared adjusting for seasonal trends in chlamydia testing and differences in practice size. Intervention effect modification was assessed for the following general practice characteristics: chlamydia testing rate compared to national median, number of general practice staff employed, payment for chlamydia screening, practice urban/rurality classification, and proximity to sexual health clinics.

Results

The 460 participating practices conducted 26,021 tests in the control period and 18,797 tests during the intervention period. Intention-to-treat analysis showed no change in the unadjusted median tests and diagnoses per month per practice after receiving training: 2.7 vs 2.7; 0.1 vs 0.1. Multivariable negative binomial regression analysis found no significant change in overall testing or diagnoses post-intervention (incidence rate ratio (IRR) 1.01, 95 % confidence interval (CI) 0.96–1.07, P = 0.72; 0.98 CI 0.84–1.15, P = 0.84, respectively). Stratified analysis showed testing increased significantly in practices where payments were in place prior to the intervention (IRR 2.12 CI 1.41–3.18, P < 0.001) and in practices with 6–15 staff (6–10 GPs IRR 1.35 (1.07–1.71), P = 0.012; 11–15 GPs IRR 1.37 (1.09–1.73), P = 0.007).

Conclusion

This national pilot of short educational training sessions found no overall effect on chlamydia testing in primary care. However, in certain sub-groups chlamydia testing rates increased due to the intervention. This demonstrates the importance of piloting and evaluating any service improvement intervention to assess the impact before widespread implementation, and the need for detailed understanding of local services in order to select effective interventions.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3343-z) contains supplementary material, which is available to authorized users.

How much information about antibiotics do people recall after consulting in primary care?

BACKGROUND

Sharing information with patients within a consultation about their infection and value of antibiotics can help reduce antibiotic prescriptions for respiratory tract infections. However, we do not know how often information is given about antibiotics or infections, and if this is related to knowledge and attitudes.

OBJECTIVES

To determine the public's reported use of antibiotics, receipt of information from health professionals about antibiotics and resistance, trust in health professionals and knowledge levels about antibiotics and resistance.

METHODS

Face-to-face computer-assisted survey with 1625 adults over 15 years in randomly selected households using multistage sampling. Rim weighting was used to correct for any selection biases.

RESULTS

About 88% trusted their GP to determine the need for antibiotics. Of those who took antibiotics in the past year, 62% were for a throat infection, 60% for sinus infection and 42% for a cough. Although 67% who had been prescribed an antibiotic recalled being given advice about their infection or antibiotics, only 8% recalled information about antibiotic resistance. Those in lower social grades were less likely to recall advice. About 44% correctly indicated that antibiotics effectively treat bacterial rather than viral infections. Only 45% agreed that 'healthy people can carry antibiotic resistant bacteria'.

CONCLUSION

GPs and health carers are trusted decision-makers, but could share more information with patients about the need or not for antibiotics, self-care and antibiotic resistance, especially with younger patients and those of lower social grade. Better ways are needed for effective sharing of information about antibiotic resistance.

Tools to overcome potential barriers to chlamydia screening in general practice: Qualitative evaluation of the implementation of a complex intervention

BACKGROUND

Chlamydia trachomatis remains a significant public health problem. We used a complex intervention, with general practice staff, consisting of practice based workshops, posters, computer prompts and testing feedback and feedback to increase routine chlamydia screening tests in under 25 year olds in South West England. We aimed to evaluate how intervention components were received by staff and to understand what determined their implementation into ongoing practice.

METHODS

We used face-to-face and telephone individual interviews with 29 general practice staff analysed thematically within a Normalisation Process Theory Framework which explores: 1. Coherence (if participants understand the purpose of the intervention); 2. Cognitive participation (engagement with and implementation of the intervention); 3. Collective action (work actually undertaken that drives the intervention forwards); 4. Reflexive monitoring (assessment of the impact of the intervention).

RESULTS

Our results showed coherence as all staff including receptionists understood the purpose of the training was to make them aware of the value of chlamydia screening tests and how to increase this in their general practice. The training was described by nearly all staff as being of high quality and responsible for creating a shared understanding between staff of how to undertake routine chlamydia screening. Cognitive participation in many general practice staff teams was demonstrated through their engagement by meeting after the training to discuss implementation, which confirmed the role of each staff member and the use of materials. However several participants still felt unable to discuss chlamydia in many consultations or described sexual health as low priority among colleagues. National targets were considered so high for some general practice staff that they didn't engage with the screening intervention. Collective action work undertaken to drive the intervention included use of computer prompts which helped staff remember to make the offer, testing rate feedback and having a designated lead. Ensuring patients collected samples when still in the general practice was not attained in most general practices. Reflexive monitoring showed positive feedback from patients and other staff about the value of screening, and feedback about the general practices testing rates helped sustain activity.

CONCLUSIONS

A complex intervention including interactive workshops, materials to help implementation and feedback can help chlamydia screening testing increase in general practices.

Implementation of antimicrobial stewardship interventions recommended by national toolkits in primary and secondary healthcare sectors in England: TARGET and Start Smart Then Focus

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.

Delayed/back up antibiotic prescriptions: what do the public think?

OBJECTIVE

To describe the general public's understanding, acceptance and use of delayed antibiotics.

DESIGN

Face to face computer-assisted survey using an Ipsos MORI Capibus survey.

SETTING

Randomly selected households in England using multistage sampling.

RESPONDENTS

A representative sample of 1625 adults aged over 15 years and recruited from household visits in England, using age and gender quotas for each area.

DATA COLLECTION AND ANALYSIS

The survey was undertaken in January 2014. Weights based on gender, age, ethnicity, working status, social grade, housing tenure and Government Office Region corrected for selection biases, so that results are broadly representative of the population.

MAIN OUTCOMES MEASURES

Proportion of respondents; understanding the meaning of the term delayed antibiotic prescription and how the strategy is used in general practice; in favour of, or opposed to clinicians offering them a delayed antibiotic; reporting receipt, use and acceptability of delayed antibiotic prescriptions in the past year.

RESULTS

17% reported fully understanding the meaning of delayed antibiotic prescription and strategy use in general practice;72% were unaware of the term or strategy; 36-39% were in favour of, and 28-30% opposed to clinicians offering them a delayed antibiotic for throat, urine, ear or chest infections. Half of those who were fully aware of the term and practice were in favour of delayed antibiotics. Women, and older respondents, were more strongly opposed to delayed prescribing. Only 4% of all respondents, and 15% of those prescribed an antibiotic, reported being offered a delayed antibiotic in the last year.

CONCLUSIONS

Wider understanding and acceptance of delayed prescribing may facilitate increased uptake. Further research is needed to determine why groups are so strongly in favour or opposed to delayed prescribing.

Do English NHS Microbiology laboratories offer adequate services for the diagnosis of UTI in children? Healthcare Quality Improvement Partnership (HQIP) Audit of Standard Operational Procedures

The National Institute of Care Excellence (NICE) 2007 guidance CG54, on urinary tract infection (UTI) in children, states that clinicians should use urgent microscopy and culture as the preferred method for diagnosing UTI in the hospital setting for severe illness in children under 3 years old and from the GP setting in children under 3 years old with intermediate risk of severe illness. NICE also recommends that all 'infants and children with atypical UTI (including non-Escherichia coli infections) should have renal imaging after a first infection'. We surveyed all microbiology laboratories in England with Clinical Pathology Accreditation to determine standard operating procedures (SOPs) for urgent microscopy, culture and reporting of children's urine and to ascertain whether the SOPs facilitate compliance with NICE guidance. We undertook a computer search in six microbiology laboratories in south-west England to determine urine submissions and urine reports in children under 3 years. Seventy-three per cent of laboratories (110/150) participated. Enterobacteriaceae that were not E. coli were reported only as coliforms (rather than non-E. coli coliforms) by 61% (67/110) of laboratories. Eighty-eight per cent of laboratories (97/110) provided urgent microscopy for hospital and 54% for general practice (GP) paediatric urines; 61% of laboratories (confidence interval 52-70%) cultured 1 μl volume of urine, which equates to one colony if the bacterial load is 106 c.f.u. l(-1). Only 22% (24/110) of laboratories reported non-E. coli coliforms and provided urgent microscopy for both hospital and GP childhood urines; only three laboratories also cultured a 5 μl volume of urine. Only one of six laboratories in our submission audit had a significant increase in urine submissions and urines reported from children less than 3 years old between the predicted pre-2007 level in the absence of guidance and the 2008 level following publication of the NICE guidance. Less than a quarter of laboratories were providing a service that would allow clinicians to fully comply with the first line recommendations in the 2007 NICE UTI in children guidance. Laboratory urine submission report figures suggest that the guidance has not led to an increase in diagnosis of UTI in children under 3 years old.

Supporting general practices to provide sexual and reproductive health services: protocol for the 3Cs & HIV programme

OBJECTIVES

Sexually transmitted infections, HIV and unplanned pregnancies continue to be a major public health problem in England, especially in young adults. Strengthening the provision of free condoms, HIV testing, chlamydia screening and contraception within primary care will contribute to reducing poor sexual and reproductive health outcomes. Recent research demonstrated the benefit for general practices of educational support visits based on behaviour change theory. Public Health England (PHE) has piloted an educational training programme to improve the delivery of sexual health services and HIV testing within general practice.

STUDY DESIGN & METHODS

The 3Cs & HIV programme used practice based workshops to improve staffs' awareness and skills in order to increase opportunistic offers of chlamydia testing, provision of contraceptive service information and free condoms (the '3Cs') to 15-24 year olds and HIV testing according to national guidelines. The programme was based on the theory of planned behaviour and has been implemented using a stepped wedge design. Process evaluation, testing and diagnosis data, plus qualitative interviews were all used in the evaluation. The primary outcome measures were chlamydia testing and diagnosis rates. Secondary outcome measures were HIV testing and diagnoses rates within each practice and rates of consultations where long acting reversible contraceptives had been discussed.

CONCLUSION

A key strength of the 3Cs & HIV programme has been the evidence base underpinning the development of the resources and the formal process evaluation of its implementation. The programme was designed to encourage sustainable relationships between general practice staff and local sexual health services as well as the knowledge, awareness and behaviours cultivated during the programme.

Longitudinal trends and cross-sectional analysis of English national hospital antibacterial use over 5 years (2008-13): working towards hospital prescribing quality measures

OBJECTIVES

There is global concern that antimicrobial resistance is a major threat to healthcare. Antimicrobial use is a primary driver of resistance but little information exists about the variation in antimicrobial use in individual hospitals in England over time or comparative use between hospitals. The objective of this study was to collate, analyse and report issue data from pharmacy records of 158 National Health Service (NHS) acute hospitals.

METHODS

This was a cohort study of inpatient antibacterial use in acute hospitals in England analysed over 5 years through a data warehouse from IMS Health, a leading provider of information, services and technology for the healthcare industry. Around 98% of NHS hospitals were included in a country with a population of 50 million residents.

RESULTS

There was a dramatic change in the usage of different groups of antibacterials between 2009 and 2013 with a marked reduction in the use of first-generation cephalosporins by 24.7% and second-generation cephalosporins by 41%, but little change in the use of third-generation cephalosporins (+5.7%) and fluoroquinolones (+1.6%). In contrast, use of co-amoxiclav, carbapenems and piperacillin/tazobactam increased by 60.1%, 61.4% and 94.8%, respectively. There was wide variation in the total and relative amounts of antibacterials used between individual hospitals.

CONCLUSIONS

Longitudinal analysis of antibacterial use demonstrated remarkable changes in NHS hospitals, probably reflecting governmental and professional guidance to mitigate the risk of Clostridium difficile infection. The wide variation in usage between individual hospitals suggests potential for quality improvement and benchmarking. Quality measures of optimal hospital antimicrobial prescribing need urgent development and validation to support antimicrobial stewardship initiatives.

Fun on the farm: evaluation of a lesson to teach students about the spread of infection on school farm visits

Background

School visits to farms are a positive educational experience but pose risks due to the spread of zoonotic infections. A lesson plan to raise awareness about microbes on the farm and preventative behaviours was developed in response to the Griffin Investigation into the E. coli outbreak associated with Godstone Farm in 2009. This study evaluated the effectiveness of the delivery of the lesson plan in increasing knowledge about the spread of infection on the farm, amongst school students.

Methods

Two hundred and twenty-five 9–11 year old students from seven junior schools in England participated. Two hundred and ten students filled in identical questionnaires covering microbes, hand hygiene, and farm hygiene before and after the lesson. Statistical analysis assessed knowledge change using difference in percentage correct answers.

Results

Significant knowledge improvement was observed for all sections. In the ‘Farm Hygiene’ section, girls and boys demonstrated 18% (p<0.001) and 11% (p<0.001) improvement, respectively (girls vs. boys p<0.004). As girls had lower baseline knowledge the greater percentage improvement resulted in similar post intervention knowledge scores between genders (girls 80%, boys 83%).

Conclusions

The lesson plan was successful at increasing awareness of microbes on the farm and infection prevention measures and should be used by teachers in preparation for a farm visit.

Current initiatives to improve prudent antibiotic use amongst school-aged children

High rates of antimicrobial prescribing for children, combined with widespread misunderstanding among the general public about the appropriate use of antibiotics, are major causes for concern. European Antibiotic Awareness Day (EAAD) is an annual event that aims to raise awareness of how to use antibiotics in a responsible way that will help keep them effective for the future. As part of EAAD 2013, this article provides an overview of some initiatives aimed at limiting the extent of inappropriate antibiotic use in children.

Increasing chlamydia screening tests in general practice: a modified Zelen prospective Cluster Randomised Controlled Trial evaluating a complex intervention based on the Theory of Planned Behaviour

OBJECTIVE

To determine if a structured complex intervention increases opportunistic chlamydia screening testing of patients aged 15-24 years attending English general practitioner (GP) practices.

METHODS

A prospective, Cluster Randomised Controlled Trial with a modified Zelen design involving 160 practices in South West England in 2010. The intervention was based on the Theory of Planned Behaviour (TPB). It comprised of practice-based education with up to two additional contacts to increase the importance of screening to GP staff and their confidence to offer tests through skill development (including videos). Practical resources (targets, posters, invitation cards, computer reminders, newsletters including feedback) aimed to actively influence social cognitions of staff, increasing their testing intention.

RESULTS

Data from 76 intervention and 81 control practices were analysed. In intervention practices, chlamydia screening test rates were 2.43/100 15-24-year-olds registered preintervention, 4.34 during intervention and 3.46 postintervention; controls testing rates were 2.61/100 registered patients prior intervention, 3.0 during intervention and 2.82 postintervention. During the intervention period, testing in intervention practices was 1.76 times as great (CI 1.24 to 2.48) as controls; this persisted for 9 months postintervention (1.57 times as great, CI 1.27 to 2.30). Chlamydia infections detected increased in intervention practices from 2.1/1000 registered 15-24-year-olds prior intervention to 2.5 during the intervention compared with 2.0 and 2.3/1000 in controls (Estimated Rate Ratio intervention versus controls 1.4 (CI 1.01 to 1.93).

CONCLUSIONS

This complex intervention doubled chlamydia screening tests in fully engaged practices. The modified Zelen design gave realistic measures of practice full engagement (63%) and efficacy of this educational intervention in general practice; it should be used more often.

TRIAL REGISTRATION

The trial was registered on the UK Clinical Research Network Study Portfolio database. UKCRN number 9722.

Education of healthcare professionals and the public

In the winter of 2007-08 a new public-facing antimicrobial campaign was agreed by the Advisory Committee on Antimicrobial Resistance and Healthcare-Associated Infection (ARHAI) Education sub-Group (later divided into subgroups for professional and public education): it comprised posters with a positive message on how the public could help themselves when they had a cold. However, the poster campaign, used in isolation in England, did not improve antibiotic use; therefore, the Public Education sub-Group took forward educational approaches to change the behaviour of the public and health professionals. Professionals have been encouraged to give patients clear information about the likely duration of symptoms, self-care, and benefits and harms of antibiotics, reinforcing the public poster campaigns in surgeries, hospitals and pharmacies. Since 2008, campaigns have been launched in England to coincide with European Antibiotic Awareness Day (EAAD) on 18 November, using Department of Health and EAAD materials. Professional education has been facilitated by the 2008 National Institute for Health and Clinical Excellence respiratory tract infection delayed prescribing guidance for general practitioners. A toolkit of materials for medicines management teams, to facilitate good antimicrobial stewardship in primary care (ASPIC), is being taken forward by the Public Education sub-Group and professional societies. After advice from ARHAI, in 2009 the General Medical Council requested that all postgraduate deans and Royal Colleges ensure infection prevention and control and antimicrobial prescribing become standard practice implemented in all clinical settings, and that they are emphasized strongly in undergraduate and postgraduate medical training. ARHAI has also taken a keen interest in reviewing, advising and leading on a number of European Union initiatives dealing with professional education.

European Antibiotic Awareness Day 2012: general practitioners encouraged to TARGET antibiotics through guidance, education and tools

On 18 November 2012, the UK will once again support the annual European Antibiotic Awareness Day (EAAD). In particular, hospitals will be asked to promote the Start Smart-Then Focus guidance for hospitals launched in 2011, while the Royal College of General Practitioners will publish the TARGET Antibiotics toolkit on their web site. TARGET (Treat Antibiotics Responsibly, Guidance, Education, Tools) emphasizes the need for both primary care staff and the public to use antibiotics responsibly, and provides guidance, education and tools. The web site has been developed by a multiprofessional group and hosts national antibiotic guidance, an antibiotic app, leaflets designed to be shared by patients during consultations, a presentation for clinicians, an interactive self-assessment tool, audit tools, posters and videos for the waiting room and links to other materials. The EAAD is still very relevant and worth promoting enthusiastically through all clinical professionals in an effort to encourage responsible use of antibiotics and thereby control antibiotic resistance.

Stool submission by general practitioners in SW England - when, why and how? A qualitative study

Background

We know little about when and why general practitioners (GPs) submit stool specimens in patients with diarrhoea. The recent UK-wide intestinal infectious disease (IID2) study found ten GP consultations for every case reported to national surveillance. We aimed to explore what factors influence GP’s decisions to send stool specimens for laboratory investigation, and what guidance, if any, informs them.

Methods

We used qualitative methods that enabled us to explore opinions and ask open questions through 20 telephone interviews with GPs with a range of stool submission rates in England, and a discussion group with 24 GPs. Interviews were transcribed and subjected to content analysis.

Results

Interviews: GPs only sent stool specimens to microbiology if diarrhoea persisted for over one week, after recent travel, or the patient was very unwell. Very few had a systematic approach to determine the clinical or public health need for a stool specimen. Only two GPs specifically asked patients about blood in their stool; only half asked about recent antibiotics, or potential food poisoning, and few asked about patients’ occupations. Few GPs gave patients advice on how to collect specimens.

Results from interviews and discussion group in relation to guidance: All reported that the HPA stool guidance and patient collection instructions would be useful in their clinical work, but only one GP (an interviewee) had previously accessed them. The majority of GPs would value links to guidance on electronic requests. Most GPs were surprised that a negative stool report did not exclude all the common causes of IID.

Conclusions

GPs value stool culture and laboratories should continue to provide it. Patient instructions on how to collect stool specimens should be within stool collection kits. Through readily accessible guidance and education, GPs need to be encouraged to develop a more systematic approach to eliciting and recording details in the patient’s history that indicate greater risk of severe infection or public health consequences. Mild or short duration IID (under one week) due to any cause is less likely to be picked up in national surveillance as GPs do not routinely submit specimens in these cases.

Is Helicobacter pylori antibiotic resistance surveillance needed and how can it be delivered?

BACKGROUND

Most patients are prescribed Helicobacter pylori treatment without culture and antibiotic susceptibility testing, as current guidance recommends that patients with recurrent dyspepsia should be tested for H. pylori using a non-invasive breath or faecal antigen test.

AIMS

To determine the prevalence of H. pylori antibiotic resistance in patients attending endoscopy in England and Wales, and the feasibility of an antibiotic resistance surveillance programme testing.

METHODS

We tested the antibiotic susceptibility of H. pylori isolates from biopsy specimens from 2063 of 7791 (26%) patients attending for endoscopy in Gloucester and Bangor, and 339 biopsy specimens sent to the Helicobacter Reference Unit (HRU) in London. Culture and susceptibility testing was undertaken in line with National and European methods.

RESULTS

Helicobacter pylori were cultured in 6.4% of 2063 patients attending Gloucester and Bangor hospitals. Resistance to amoxicillin, tetracycline and rifampicin/rifabutin was below 3% at all centres. Clarithromycin, metronidazole and quinolone resistance was significantly higher in HRU (68%, 88%, 17%) and Bangor isolates (18%, 43%, 13%) than Gloucester (3%, 22%, 1%). Each previous course of these antibiotics is associated with an increase in the risk of antibiotic resistance to that agent [clarithromycin: RR = 1.5 (P = 0.12); metronidazole RR = 1.6 (P = 0.002); quinolone RR = 1.8 (P = 0.01)].

CONCLUSIONS

Helicobacter pylori infection is now uncommon in dyspeptic patients at endoscopy. A surveillance system is feasible and necessary to inform dyspepsia management guidance. Clinicians should take a thorough antibiotic history before prescribing metronidazole, clarithromycin or levofloxacin for H. pylori.

Evaluating the online activity of users of the e-Bug web site

Web server log analysis is being increasingly used to evaluate the user behaviour on healthcare resource web sites due to the detailed record of activity that they contain. This study aimed to use this information to evaluate the e-Bug web site, a healthcare resource that provides a range of educational resources about microbes, hand and respiratory hygiene, and antibiotics. This evaluation was conducted by analysing the web server logs of the e-Bug web site for the period January 2008 to November 2009, using a proprietary application named Sawmill. The e-Bug web site has had >900,000 page views generated from >88,000 users, with an increase in May 2009 during the swine flu epidemic and a further increase in September 2009 following the official launch of e-Bug. The majority of visitors were from the UK, but visits were recorded from 190 different countries. Word(®) document resources were downloaded >169,000 times, with the most popular being a swine flu factsheet. PowerPoint(®) document resources were downloaded >36,000 times, with the most popular relating to the 'chain of infection'. The majority of visitor referrals originated from search engines, with the most popular referral keywords being variations on the e-Bug name. The most common non-search engine referrals were from other healthcare resources and agencies. Use of the site has increased markedly since the official launch of e-Bug, with average page views of >200,000 per month, from a range of countries, illustrating the international demand for a teaching resource for microbes, hygiene and antibiotics.

Computer games to teach hygiene: an evaluation of the e-Bug junior game

Handwashing, respiratory hygiene and antibiotic resistance remain major public health concerns. In order to facilitate an effective outcome when teaching the basic principles of hand and respiratory hygiene, educational interventions should first target school children. As computer games are ubiquitous in most children's lives, e-Bug developed computer games targeted at teaching children handwashing, respiratory hygiene and antibiotic resistance. The games were designed for two target audiences: junior school children (9-12 year olds); and senior school children (13-15 year olds). Between May and August 2009, the finalized junior game underwent an evaluation in three UK schools (in Glasgow, Gloucester and London), involving 62 children in the schools and ∼ 1700 players accessing the junior game online. The e-Bug junior game consists of a number of levels of play, each of which promotes a set of learning outcomes (LOs). These LOs, complementary to those in the e-Bug packs, are expressed through the game mechanics (the rules of the game) rather than through story or dialogue. Although the junior game's evaluation demonstrated a statistically significant change in the knowledge for only a small number of given LOs, because many children had the required knowledge already before playing the game, this is e-Bug's first statistical study on the junior game and the first comprehensive evaluation of its kind. Future work includes a re-examination of the quiz-style questionnaires utilized in this study and an exploration of the potential knowledge change acquired strictly through engagement.

What are school children in Europe being taught about hygiene and antibiotic use?

e-Bug is a pan-European antibiotic and hygiene teaching resource that aims to reinforce awareness in school children of microbes, prudent antibiotic use, hygiene and the transmission of infection. Prior to the production of the resource, it was essential to examine the educational structure across each partner country and assess what school children were being taught on these topics. A questionnaire was devised for distribution to each European partner (Belgium, Czech Republic, Denmark, England, France, Greece, Italy, Poland, Portugal and Spain), exploring their educational structure and examining educational resources or campaigns currently available. From the data collected it was evident that the majority of European schools have structured hand hygiene practices in place from a young age. The curricula in all countries cover the topic of human health and hygiene, but limited information is provided on antibiotics and their prudent use. School educational resources that link to the national curriculum and implement National Advice to the Public campaigns in the classroom are limited. The Microbes en question mobile health education campaign in France is an example of a successful children's education campaign and an innovative programme. Evaluation of the impact of school education on attitude and change of behaviour is also limited throughout many European countries. Not enough is currently being done across Europe to educate school children on the importance of appropriate antibiotic use and antibiotic resistance. The data from this research were used to develop e-Bug, a European Union-funded antibiotic and hygiene teaching resource.

Development of an educational resource on microbes, hygiene and prudent antibiotic use for junior and senior school children

Health promotion interventions aimed at children and young people have the potential to lay the foundations for healthy lifestyles. One such intervention, e-Bug, aims to provide schoolchildren with knowledge of prudent antibiotic use and how to reduce the spread of infection. Many children and schools approach learning in different ways; therefore, it is essential to research school needs and the variety of learning styles when creating any school resources. This article outlines the process involved during the development of a pan-European educational resource, and identifies the final pack layout, based on feedback from teacher focus groups, student questionnaires and European partner discussions.

e-Bug implementation in England

e-Bug is an educational resource for schools, covering the topics of microbes and prudent antibiotic use. A coordinated implementation approach with the e-Bug team, the Department of Health, and the Department for Children, Schools and Families resulted in the dissemination of 20,500 Junior and Senior e-Bug packs to all maintained schools in England in 2010.

Developing e-Bug web games to teach microbiology

As a complement to the e-Bug teaching pack, two e-Bug games were developed to provide content that aimed to entertain as well as to educate. A set of agreed learning outcomes (LOs) were provided by the scientific partners of the e-Bug Project and the games were developed using user-centred design techniques (the needs, wants and limitations of the potential game players were assessed at each stage of the design process). The e-Bug games were designed for two age groups: Junior (9-12 year olds); and Senior (13-15 year olds). A study using focus groups was done to gain an understanding as to the types of games enjoyed by the target users. According to the preliminary study, the Junior Game was developed as a platform game and the Senior Game was developed as a story-based detective game. The Junior Game consists of five levels, each associated with a set of LOs. Similarly, the Senior Game consists of four missions, each comprising five stages using problem-based learning techniques and LOs. In this paper, the process of development for each game is described in detail and an illustration is provided of how each game level or mission addresses the target LOs. Development of the games used feedback acquired from children in four schools across the UK (Glasgow, London and two in Gloucester). The children were selected according to their willingness to participate. European Partners of the e-Bug Project also provided further support, translation and requests for modifications. The knowledge gained of LOs and further evaluation of the games is continuing, and preliminary results are in press. The final versions of the games, translated into 11 European languages, are available online via www.e-bug.eu.

Diagnosis of Helicobacter pylori Infection

When an endoscopy is performed, it now becomes easier to observe indirect evidence of the presence of a Helicobacter pylori infection, given the progress of new methods including magnifying narrow band imaging or confocal laser endomicroscopy. Out of the biopsy-based tests, the novel original method proposed concerned culture in a broth medium with or without antibiotics and ELISA detection of H. pylori. New stool antigen tests are still appearing with no major improvement in comparison with the monoclonal-based tests already on the market. The combination of pepsinogen detection to H. pylori serology is now more and more evaluated to detect preneoplastic lesions.

Microbiology Reporting of Ear Swab Results in Otitis Externa

Objective: To review current microbiology laboratory reporting of ear swab specimens in primary care and reach an evidence-based reporting policy consensus.

Method: Prospective primary care study commenced June 2006. Analyzed 50 consecutive ear swab reports of otitis externa from 12 laboratories in the southwest UK to determine reporting practice. The HPA GP Laboratory Use Group achieved consensus of expert microbiology opinion for reporting using a modified version of the Delphi technique.

Results: 487 reports were reviewed (54% female; 46% male). Pseudomonas species (36%), Staphylococcus species (21%), Streptococcus species (15%), and fungi (11%) predominated. Five reporting policies agreed. Policy 1: Common pathogens (above) — “Reported by name with antibiotic susceptibilities.” Policy 2: Pseudomonas species— “Always reported; antibiotic susceptibilities in severe disease.” Policy 3: Aspergillus, Candida, coliform etc— “Only reported if moderate numbers of colonies and predominant organism present; if appropriate report antibiotic susceptibilities.” Policy 4: Coagulase-negative staphylococci, diphtheroids— and enterococci, “generic terms used; susceptibilities not reported.” Policy 5: “When antibiotic susceptibilities reported, these should include susceptibility to a topical antibiotic.”

Conclusion: This paper provides microbiology laboratories with consensus reporting guidelines for ear swabs of otitis externa.

Learning by gaming - evaluation of an online game for children

Playing computer games is widely popular among children and teenagers as an entertainment activity; meanwhile, playing computer games also provides a learning opportunity. For example, the rules of the game have to be learned by the player in order to improve his/her performance. Based on that principle, the City eHealth Research Centre (CeRC) developed a web game for 13-15 year olds, whereby the player becomes an investigator who attends the scene of an incident that involves microbes. There are four missions in total, each involving a mystery that the player needs to solve and learning objectives that need to be taught - such as antibiotic resistance and the importance of hygiene. This paper presents the results from a game evaluation that took place between July of 2009, in four UK schools (Glasgow, Gloucester, London), with 129 students; whereby 98% of the students commented positively about playing the game. Subsequently, CeRC has improved the game and developed an interactive educational games portal (www.edugames4all.com) for different age groups of web game enthusiasts.