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McBride A, Duyen HTL, Vuong NL, Tho PV, Tai LTH, Phong NT, Ngoc NT, Yen LM, Nhat PTH, Vi TT, Llewelyn MJ, Thwaites L, Hao NV, Yacoub S. Endothelial and inflammatory pathophysiology in dengue shock: New insights from a prospective cohort study in Vietnam. PLoS Negl Trop Dis 2024; 18:e0012071. [PMID: 38536887 PMCID: PMC11020502 DOI: 10.1371/journal.pntd.0012071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 04/16/2024] [Accepted: 03/14/2024] [Indexed: 04/18/2024] Open
Abstract
Dengue shock (DS) is the most severe complication of dengue infection; endothelial hyperpermeability leads to profound plasma leakage, hypovolaemia and extravascular fluid accumulation. At present, the only treatment is supportive with intravenous fluid, but targeted endothelial stabilising therapies and host immune modulators are needed. With the aim of prioritising potential therapeutics, we conducted a prospective observational study of adults (≥16 years) with DS in Vietnam from 2019-2022, comparing the pathophysiology underlying circulatory failure with patients with septic shock (SS), and investigating the association of biomarkers with clinical severity (SOFA score, ICU admission, mortality) and pulmonary vascular leak (daily lung ultrasound for interstitial and pleural fluid). Plasma was collected at enrolment, 48 hours later and hospital discharge. We measured biomarkers of inflammation (IL-6, ferritin), endothelial activation (Ang-1, Ang-2, sTie-2, VCAM-1) and endothelial glycocalyx breakdown (hyaluronan, heparan sulfate, endocan, syndecan-1). We enrolled 135 patients with DS (median age 26, median SOFA score 7, 34 required ICU admission, 5 deaths), together with 37 patients with SS and 25 healthy controls. Within the DS group, IL-6 and ferritin were associated with admission SOFA score (IL-6: βeta0.70, p<0.001 & ferritin: βeta0.45, p<0.001), ICU admission (IL-6: OR 2.6, p<0.001 & ferritin: OR 1.55, p<0.001) and mortality (IL-6: OR 4.49, p = 0.005 & ferritin: OR 13.8, p = 0.02); both biomarkers discriminated survivors and non-survivors at 48 hours and all patients who died from DS had pre-mortem ferritin ≥100,000ng/ml. IL-6 most strongly correlated with severity of pulmonary vascular leakage (R = 0.41, p<0.001). Ang-2 correlated with pulmonary vascular leak (R = 0.33, p<0.001) and associated with SOFA score (β 0.81, p<0.001) and mortality (OR 8.06, p = 0.002). Ang-1 was associated with ICU admission (OR 1.6, p = 0.005) and mortality (OR 3.62, p = 0.006). All 4 glycocalyx biomarkers were positively associated with SOFA score, but only syndecan-1 was associated with ICU admission (OR 2.02, p<0.001) and mortality (OR 6.51, p<0.001). This study highlights the central role of hyperinflammation in determining outcomes from DS; the data suggest that anti-IL-1 and anti-IL-6 immune modulators and Tie2 agonists may be considered as candidates for therapeutic trials in severe dengue.
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Affiliation(s)
- Angela McBride
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Brighton and Sussex Medical School, Brighton, United Kingdom
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | | | - Nguyen Lam Vuong
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
| | - Phan Vinh Tho
- Hospital for Tropical Disease, Ho Chi Minh City, Vietnam
| | | | | | | | - Lam Minh Yen
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | - Tran Thuy Vi
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | - Louise Thwaites
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Nguyen Van Hao
- Hospital for Tropical Disease, Ho Chi Minh City, Vietnam
| | - Sophie Yacoub
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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L A Cross E, Quan TP, Hayward GN, Walker AS, Llewelyn MJ. Development and validation of the Baseline Recurrence Risk in Cellulitis (BRRISC) score. J Infect 2024; 88:103-111. [PMID: 38128701 DOI: 10.1016/j.jinf.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 11/16/2023] [Accepted: 12/14/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVES Cellulitis is often treated with antibiotics for longer than recommended by guidelines. Prolonged therapy may reduce recurrence in certain patients, but it is not known which patients are at greatest risk. Our objective was to develop and temporally validate a risk prediction score to identify patients attending hospital with cellulitis at highest risk of recurrence. METHODS We included UK adult patients with cellulitis attending hospital in an electronic health records (EHR) study to identify demographic, comorbid, physiological, and laboratory factors predicting recurrence (before death) within 90 days, using multivariable logistic regression with backwards elimination in complete cases. A points-based risk score integerised model coefficients for selected predictors. Performance was assessed using the C-index in development and temporal validation samples. RESULTS The final model included 4938 patients treated for median 8 days (IQR 6-11); 8.8% (n = 436) experienced hospitalisation-associated recurrence. A risk score using eight variables (age, heart rate, urea, platelets, albumin, previous cellulitis, venous insufficiency, and liver disease) ranged from 0-15, with C-index = 0.65 (95%CI: 0.63-0.68). Categorising as low (score 0-1), medium (2-5) and high (6-15) risk, recurrence increased fourfold; 3.2% (95%CI: 2.3-4.4%), 9.7% (8.7-10.8%), and 16.6% (13.3-20.4%). Performance was maintained in the validation sample (C-index = 0.63 (95%CI: 0.58-0.67)). Among patients at high risk, four distinct clinical phenotypes were identified using hierarchical clustering 1) young, acutely unwell with liver disease; 2) comorbid with previous cellulitis and venous insufficiency; 3) chronic renal disease with severe renal impairment; and 4) acute severe illness, with substantial inflammatory responses. CONCLUSIONS Risk of cellulitis recurrence varies markedly according to individual patient factors captured in the Baseline Recurrence Risk in Cellulitis (BRRISC) score. Further work is needed to optimise the score, considering baseline and treatment response variables not captured in EHR data, and establish the utility of risk-based approaches to guide optimal antibiotic duration.
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Affiliation(s)
- Elizabeth L A Cross
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Falmer BN1 9PS, UK
| | - T Phuong Quan
- Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK; NIHR Biomedical Research Centre, Oxford OX3 9DU, UK; National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford OX3 9DU, UK
| | - Gail N Hayward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Rd, Oxford OX2 6GG, UK
| | - A Sarah Walker
- Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK; NIHR Biomedical Research Centre, Oxford OX3 9DU, UK; National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford OX3 9DU, UK
| | - Martin J Llewelyn
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Falmer BN1 9PS, UK.
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Zuercher P, Moser A, Garcia de Guadiana-Romualdo L, Llewelyn MJ, Graf R, Reding T, Eggimann P, Que YA, Prazak J. Discriminative performance of pancreatic stone protein in predicting ICU mortality and infection severity in adult patients with infection: a systematic review and individual patient level meta-analysis. Infection 2023; 51:1797-1807. [PMID: 37707744 PMCID: PMC10665254 DOI: 10.1007/s15010-023-02093-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 08/30/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Several studies suggested pancreatic stone protein (PSP) as a promising biomarker to predict mortality among patients with severe infection. The objective of the study was to evaluate the performance of PSP in predicting intensive care unit (ICU) mortality and infection severity among critically ill adults admitted to the hospital for infection. METHODS A systematic search across Cochrane Central Register of Controlled Trials and MEDLINE databases (1966 to February 2022) for studies on PSP published in English using 'pancreatic stone protein', 'PSP', 'regenerative protein', 'lithostatin' combined with 'infection' and 'sepsis' found 46 records. The search was restricted to the five trials that measured PSP using the enzyme-linked immunosorbent assay technique (ELISA). We used Bayesian hierarchical regression models for pooled estimates and to predict mortality or disease severity using PSP, C-Reactive Protein (CRP) and procalcitonin (PCT) as main predictor. We used statistical discriminative measures, such as the area under the receiver operating characteristic curve (AUC) and classification plots. RESULTS Among the 678 patients included, the pooled ICU mortality was 17.8% (95% prediction interval 4.1% to 54.6%) with a between-study heterogeneity (I-squared 87%). PSP was strongly associated with ICU mortality (OR = 2.7, 95% credible interval (CrI) [1.3-6.0] per one standard deviation increase; age, gender and sepsis severity adjusted OR = 1.5, 95% CrI [0.98-2.8]). The AUC was 0.69 for PSP 95% confidence interval (CI) [0.64-0.74], 0.61 [0.56-0.66] for PCT and 0.52 [0.47-0.57] for CRP. The sensitivity was 0.96, 0.52, 0.30 for risk thresholds 0.1, 0.2 and 0.3; respective false positive rate values were 0.84, 0.25, 0.10. CONCLUSIONS We found that PSP showed a very good discriminative ability for both investigated study endpoints ICU mortality and infection severity; better in comparison to CRP, similar to PCT. Combinations of biomarkers did not improve their predictive ability.
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Affiliation(s)
- Patrick Zuercher
- Department of Intensive Care Medicine, INO E-104, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - André Moser
- CTU Bern, University of Bern, Bern, Switzerland
| | | | - Martin J Llewelyn
- University Hospitals Sussex NHS Foundation Trust, Brighton BN2 5BE UK and Brighton and Sussex Medical School, Falmer, BN1 9PS, UK
| | - Rolf Graf
- Department of Visceral and Transplantation Surgery, Universitätsspital Zürich, Zurich, Switzerland
| | - Theresia Reding
- Department of Visceral and Transplantation Surgery, Universitätsspital Zürich, Zurich, Switzerland
| | - Philippe Eggimann
- Department of Locomotor Apparatus, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Yok-Ai Que
- Department of Intensive Care Medicine, INO E-104, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Josef Prazak
- Department of Intensive Care Medicine, INO E-104, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland.
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Liu X, Munro APS, Wright A, Feng S, Janani L, Aley PK, Babbage G, Baker J, Baxter D, Bawa T, Bula M, Cathie K, Chatterjee K, Dodd K, Enever Y, Fox L, Qureshi E, Goodman AL, Green CA, Haughney J, Hicks A, Jones CE, Kanji N, van der Klaauw AA, Libri V, Llewelyn MJ, Mansfield R, Maallah M, McGregor AC, Minassian AM, Moore P, Mughal M, Mujadidi YF, Belhadef HT, Holliday K, Osanlou O, Osanlou R, Owens DR, Pacurar M, Palfreeman A, Pan D, Rampling T, Regan K, Saich S, Saralaya D, Sharma S, Sheridan R, Stokes M, Thomson EC, Todd S, Twelves C, Read RC, Charlton S, Hallis B, Ramsay M, Andrews N, Lambe T, Nguyen-Van-Tam JS, Cornelius V, Snape MD, Faust SN. Persistence of immune responses after heterologous and homologous third COVID-19 vaccine dose schedules in the UK: eight-month analyses of the COV-BOOST trial. J Infect 2023; 87:18-26. [PMID: 37085049 PMCID: PMC10116128 DOI: 10.1016/j.jinf.2023.04.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/30/2023] [Accepted: 04/18/2023] [Indexed: 04/23/2023]
Abstract
BACKGROUND COV-BOOST is a multicentre, randomised, controlled, phase 2 trial of seven COVID-19 vaccines used as a third booster dose in June 2021. Monovalent messenger RNA (mRNA) COVID-19 vaccines were subsequently widely used for the third and fourth-dose vaccination campaigns in high-income countries. Real-world vaccine effectiveness against symptomatic infections following third doses declined during the Omicron wave. This report compares the immunogenicity and kinetics of responses to third doses of vaccines from day (D) 28 to D242 following third doses in seven study arms. METHODS The trial initially included ten experimental vaccine arms (seven full-dose, three half-dose) delivered at three groups of six sites. Participants in each site group were randomised to three or four experimental vaccines, or MenACWY control. The trial was stratified such that half of participants had previously received two primary doses of ChAdOx1 nCov-19 (Oxford-AstraZeneca; hereafter referred to as ChAd) and half had received two doses of BNT162b2 (Pfizer-BioNtech, hereafter referred to as BNT). The D242 follow-up was done in seven arms (five full-dose, two half-dose). The BNT vaccine was used as the reference as it was the most commonly deployed third-dose vaccine in clinical practice in high-income countries. The primary analysis was conducted using all randomised and baseline seronegative participants who were SARS-CoV-2 naïve during the study and who had not received a further COVID-19 vaccine for any reason since third dose randomisation. RESULTS Among the 817 participants included in this report, the median age was 72 years (IQR: 55-78) with 50.7% being female. The decay rates of anti-spike IgG between vaccines are different among both populations who received initial doses of ChAd/ChAd and BNT/BNT. In the population that previously received ChAd/ChAd, mRNA vaccines had the highest titre at D242 following their vaccine dose although Ad26. COV2. S (Janssen; hereafter referred to as Ad26) showed slower decay. For people who received BNT/BNT as their initial doses, a slower decay was also seen in the Ad26 and ChAd arms. The anti-spike IgG became significantly higher in the Ad26 arm compared to the BNT arm as early as 3 months following vaccination. Similar decay rates were seen between BNT and half-BNT; the geometric mean ratios ranged from 0.76 to 0.94 at different time points. The difference in decay rates between vaccines was similar for wild-type live virus-neutralising antibodies and that seen for anti-spike IgG. For cellular responses, the persistence was similar between study arms. CONCLUSIONS Heterologous third doses with viral vector vaccines following two doses of mRNA achieve more durable humoral responses compared with three doses of mRNA vaccines. Lower doses of mRNA vaccines could be considered for future booster campaigns.
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Affiliation(s)
- Xinxue Liu
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK.
| | - Alasdair P S Munro
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Annie Wright
- Imperial Clinical Trials Unit, Imperial College London, London, UK
| | - Shuo Feng
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Leila Janani
- Imperial Clinical Trials Unit, Imperial College London, London, UK
| | - Parvinder K Aley
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Gavin Babbage
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Jonathan Baker
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | | | - Tanveer Bawa
- Department of Infection, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Marcin Bula
- NIHR Liverpool Clinical Research Facility, Liverpool, UK
| | - Katrina Cathie
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Krishna Chatterjee
- NIHR Cambridge Clinical Research Facility, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Kate Dodd
- NIHR Liverpool Clinical Research Facility, Liverpool, UK
| | | | - Lauren Fox
- Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Ehsaan Qureshi
- NIHR/Wellcome Clinical Research Facility, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Anna L Goodman
- Department of Infection, Guy's and St Thomas' NHS Foundation Trust, London, UK; MRC Clinical Trials Unit, University College London, London, UK
| | - Christopher A Green
- NIHR/Wellcome Clinical Research Facility, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - John Haughney
- Queen Elizabeth University Hospital, NHS Greater Glasgow & Clyde, Glasgow, UK
| | | | - Christine E Jones
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Nasir Kanji
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Agatha A van der Klaauw
- Wellcome-MRC Institute of Metabolic Science, Department of Clinical Biochemistry, University of Cambridge, Cambridge, UK
| | - Vincenzo Libri
- NIHR UCLH Clinical Research Facility and NIHR UCLH Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK
| | | | | | - Mina Maallah
- Department of Infectious Diseases and Tropical Medicine, London Northwest University Healthcare, London, UK
| | - Alastair C McGregor
- Department of Infectious Diseases and Tropical Medicine, London Northwest University Healthcare, London, UK
| | - Angela M Minassian
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; Jenner Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | | | | | | | - Kyra Holliday
- NIHR Leeds Clinical Research Facility, Leeds Teaching Hospitals Trust and University of Leeds, Leeds, UK
| | - Orod Osanlou
- Public Health Wales, Betsi Cadwaladr University Health Board, Bangor University, Bangor, UK
| | | | - Daniel R Owens
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Mihaela Pacurar
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Adrian Palfreeman
- University Hospitals of Leicester NHS Trust, University of Leicester, Leicester, UK
| | - Daniel Pan
- University Hospitals of Leicester NHS Trust, University of Leicester, Leicester, UK; Department of Respiratory Sciences, University of Leicester, Leicester, UK
| | - Tommy Rampling
- NIHR UCLH Clinical Research Facility and NIHR UCLH Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK
| | - Karen Regan
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Stephen Saich
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Dinesh Saralaya
- Bradford Institute for Health Research and Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Sunil Sharma
- University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Ray Sheridan
- Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, UK
| | - Matthew Stokes
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Emma C Thomson
- Queen Elizabeth University Hospital, NHS Greater Glasgow & Clyde, Glasgow, UK; MRC University of Glasgow Centre for Virus Research, Glasgow, UK
| | - Shirley Todd
- Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, UK
| | - Chris Twelves
- NIHR Leeds Clinical Research Facility, Leeds Teaching Hospitals Trust and University of Leeds, Leeds, UK
| | - Robert C Read
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | | | | | - Mary Ramsay
- UK Health Security Agency, Colindale, London, UK
| | - Nick Andrews
- UK Health Security Agency, Colindale, London, UK
| | - Teresa Lambe
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | | | | | - Matthew D Snape
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Saul N Faust
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK.
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Kanagaratnam P, Francis DP, Chamie D, Coyle C, Marynina A, Katritsis G, Paiva P, Szigeti M, Cole G, de Andrade Nunes D, Howard J, Esper R, Khan M, More R, Barreto G, Meneguz-Moreno R, Arnold A, Nowbar A, Kaura A, Mariveles M, March K, Shah J, Nijjer S, Lip GY, Mills N, Camm AJ, Cooke GS, Corbett SJ, Llewelyn MJ, Ghanima W, Toshner M, Peters N, Petraco R, Al-Lamee R, Boshoff ASM, Durkina M, Malik I, Ruparelia N, Cornelius V, Shun-Shin M. A RANDOMISED CONTROLLED TRIAL TO INVESTIGATE THE USE OF ACUTE CORONARY SYNDROME THERAPY IN PATIENTS HOSPITALISED WITH COVID-19: THE C19-ACS TRIAL. J Thromb Haemost 2023:S1538-7836(23)00428-2. [PMID: 37230416 DOI: 10.1016/j.jtha.2023.04.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 04/11/2023] [Accepted: 04/29/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Patients hospitalised with COVID-19 suffer thrombotic complications. Risk factors for poor outcomes are shared with coronary artery disease. OBJECTIVES To investigate efficacy of an acute coronary syndrome regimen in patients hospitalised with COVID-19 and coronary disease risk factors. PATIENTS/METHODS A randomised controlled open-label trial across acute hospitals (UK and Brazil) added aspirin, clopidogrel, low-dose rivaroxaban, atorvastatin, and omeprazole to standard care for 28-days. Primary efficacy and safety outcomes were 30-day mortality and bleeding. The key secondary outcome was a daily clinical status (at home, in hospital, on intensive therapy unit admission, death). RESULTS 320 patients from 9 centres were randomised. The trial terminated early due to low recruitment. At 30 days there was no significant difference in mortality (intervention: 11.5% vs control: 15%, unadjusted OR 0.73, 95%CI 0.38 to 1.41, p=0.355). Significant bleeds were infrequent and not significantly different between the arms (intervention: 1.9% vs control 1.9%, p>0.999). Using a Bayesian Markov longitudinal ordinal model, it was 93% probable that intervention arm participants were more likely to transition to a better clinical state each day (OR 1.46, 95% CrI 0.88 to 2.37, Pr(Beta>0)=93%; adjusted OR 1.50, 95% CrI 0.91 to 2.45, Pr(Beta>0)=95%) and median time to discharge home was two days shorter (95% CrI -4 to 0, 2% probability that it was worse). CONCLUSIONS Acute coronary syndrome treatment regimen was associated with a reduction in the length of hospital stay without an excess in major bleeding. A larger trial is needed to evaluate mortality.
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Affiliation(s)
- Prapa Kanagaratnam
- Imperial College Healthcare NHS Trust, London, UK; Imperial College, London, UK.
| | - Darrel P Francis
- Imperial College Healthcare NHS Trust, London, UK; Imperial College, London, UK
| | - Daniel Chamie
- Instituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil
| | - Clare Coyle
- Imperial College Healthcare NHS Trust, London, UK; Imperial College, London, UK
| | | | | | - Patricia Paiva
- Instituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil
| | - Matyas Szigeti
- Imperial College, London, UK; Physiological Controls Research Centre, Obuda University, Budapest, Hungary
| | - Graham Cole
- Imperial College Healthcare NHS Trust, London, UK; Imperial College, London, UK
| | | | - James Howard
- Imperial College Healthcare NHS Trust, London, UK; Imperial College, London, UK
| | | | | | - Ranjit More
- Blackpool Teaching Hospitals NHS Foundation Trust, UK
| | | | - Rafael Meneguz-Moreno
- Instituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil; Centro de Ensino e Pesquisa da Rede Primavera, Aracaju, Brazil; Universidade Federal de Sergipe, Lagarto, Brazil
| | - Ahran Arnold
- Imperial College Healthcare NHS Trust, London, UK; Imperial College, London, UK
| | | | - Amit Kaura
- Imperial College Healthcare NHS Trust, London, UK; Imperial College, London, UK
| | | | | | - Jaymin Shah
- London North West University Healthcare NHS Trust, UK
| | | | - Gregory Yh Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Nicholas Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK; Usher Institute, University of Edinburgh, Edinburgh, UK
| | - A John Camm
- St George's University of London, London, UK
| | - Graham S Cooke
- Imperial College Healthcare NHS Trust, London, UK; Imperial College, London, UK
| | | | - Martin J Llewelyn
- Brighton and Sussex Medical School, University of Sussex, Falmer, UK
| | - Waleed Ghanima
- Østfold Hospital: Kalnes, Norway; Institute of Clinical Medicine, University of Oslo, Norway
| | - Mark Toshner
- Heart and Lung Research Institute, Dept of Medicine, University of Cambridge
| | - Nicholas Peters
- Imperial College Healthcare NHS Trust, London, UK; Imperial College, London, UK
| | - Ricardo Petraco
- Imperial College Healthcare NHS Trust, London, UK; Imperial College, London, UK
| | - Rasha Al-Lamee
- Imperial College Healthcare NHS Trust, London, UK; Imperial College, London, UK
| | | | - Margarita Durkina
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London
| | - Iqbal Malik
- Imperial College Healthcare NHS Trust, London, UK; Imperial College, London, UK
| | - Neil Ruparelia
- Imperial College Healthcare NHS Trust, London, UK; Royal Berkshire Hospital NHS Trust, UK
| | - Victoria Cornelius
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London
| | - Matthew Shun-Shin
- Imperial College Healthcare NHS Trust, London, UK; Imperial College, London, UK
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Liu X, Munro AP, Feng S, Janani L, Aley PK, Babbage G, Baxter D, Bula M, Cathie K, Chatterjee K, Dejnirattisai W, Dodd K, Enever Y, Qureshi E, Goodman AL, Green CA, Harndahl L, Haughney J, Hicks A, van der Klaauw AA, Kwok J, Libri V, Llewelyn MJ, McGregor AC, Minassian AM, Moore P, Mughal M, Mujadidi YF, Holliday K, Osanlou O, Osanlou R, Owens DR, Pacurar M, Palfreeman A, Pan D, Rampling T, Regan K, Saich S, Serafimova T, Saralaya D, Screaton GR, Sharma S, Sheridan R, Sturdy A, Supasa P, Thomson EC, Todd S, Twelves C, Read RC, Charlton S, Hallis B, Ramsay M, Andrews N, Lambe T, Nguyen-Van-Tam JS, Cornelius V, Snape MD, Faust SN. Corrigendum to "Persistence of immunogenicity after seven COVID-19 vaccines given as third dose boosters following two doses of ChAdOx1 nCov-19 or BNT162b2 in the UK: Three month analyses of the COV-BOOST trial" [J Infect 84(6) (2022) 795-813, 5511]. J Infect 2023; 86:540-541. [PMID: 37055303 PMCID: PMC10089831 DOI: 10.1016/j.jinf.2023.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Affiliation(s)
- Xinxue Liu
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Alasdair Ps Munro
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Shuo Feng
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Leila Janani
- Imperial Clinical Trials Unit, Imperial College London, London, UK
| | - Parvinder K Aley
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Gavin Babbage
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Marcin Bula
- NIHR Liverpool and Broadgreen Clinical Research Facility, Liverpool, UK
| | - Katrina Cathie
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Krishna Chatterjee
- NIHR Cambridge Clinical Research Facility, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Wanwisa Dejnirattisai
- Wellcome Centre for Human Genetics, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Kate Dodd
- NIHR Liverpool and Broadgreen Clinical Research Facility, Liverpool, UK
| | | | - Ehsaan Qureshi
- NIHR/Wellcome Clinical Research Facility, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Anna L Goodman
- Department of Infection, Guy's and St Thomas' NHS Foundation Trust, London, UK; MRC Clinical Trials Unit, University College London, London, UK
| | - Christopher A Green
- NIHR/Wellcome Clinical Research Facility, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Linda Harndahl
- Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - John Haughney
- Queen Elizabeth University Hospital, NHS Greater Glasgow & Clyde, Glasgow, UK
| | | | - Agatha A van der Klaauw
- Wellcome-MRC Institute of Metabolic Science, Department of Clinical Biochemistry, University of Cambridge, Cambridge, UK
| | - Jonathan Kwok
- Cancer Research UK Oxford Centre, University of Oxford, Oxford, UK
| | - Vincenzo Libri
- NIHR UCLH Clinical Research Facility and NIHR UCLH Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Alastair C McGregor
- Department of Infectious Diseases and Tropical Medicine, London Northwest University Healthcare, London, UK
| | - Angela M Minassian
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; Jenner Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | | | | | - Kyra Holliday
- NIHR Leeds Clinical Research Facility, Leeds Teaching Hospitals Trust and University of Leeds, Leeds, UK
| | - Orod Osanlou
- Public Health Wales, Betsi Cadwaladr University Health Board, Bangor University, Bangor, UK
| | | | - Daniel R Owens
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Mihaela Pacurar
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Adrian Palfreeman
- University Hospitals of Leicester NHS Trust, University of Leicester, Leicester, UK
| | - Daniel Pan
- University Hospitals of Leicester NHS Trust, University of Leicester, Leicester, UK
| | - Tommy Rampling
- NIHR UCLH Clinical Research Facility and NIHR UCLH Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK
| | - Karen Regan
- Bradford Institute for Health Research and Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Stephen Saich
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Teona Serafimova
- Department of Infection, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Dinesh Saralaya
- Bradford Institute for Health Research and Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Gavin R Screaton
- Wellcome Centre for Human Genetics, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Sunil Sharma
- University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Ray Sheridan
- Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, UK
| | - Ann Sturdy
- Department of Infectious Diseases and Tropical Medicine, London Northwest University Healthcare, London, UK
| | - Piyada Supasa
- Wellcome Centre for Human Genetics, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Emma C Thomson
- Queen Elizabeth University Hospital, NHS Greater Glasgow & Clyde, Glasgow, UK; MRC University of Glasgow Centre for Virus Research, Glasgow, UK
| | - Shirley Todd
- Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, UK
| | - Chris Twelves
- NIHR Leeds Clinical Research Facility, Leeds Teaching Hospitals Trust and University of Leeds, Leeds, UK
| | - Robert C Read
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | | | | | - Mary Ramsay
- UK Health Security Agency, Colindale, London, UK
| | - Nick Andrews
- UK Health Security Agency, Colindale, London, UK
| | - Teresa Lambe
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | | | | | - Matthew D Snape
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Saul N Faust
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK.
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7
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Edwards G, Seeley A, Carter A, Patrick Smith M, Cross ELA, Hughes K, Van den Bruel A, Llewelyn MJ, Verbakel JY, Hayward G. What is the Diagnostic Accuracy of Novel Urine Biomarkers for Urinary Tract Infection? Biomark Insights 2023; 18:11772719221144459. [PMID: 36761839 PMCID: PMC9902898 DOI: 10.1177/11772719221144459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 10/31/2022] [Indexed: 01/26/2023] Open
Abstract
Background Urinary tract infection (UTI) affects half of women at least once in their lifetime. Current diagnosis involves urinary dipstick and urine culture, yet both methods have modest diagnostic accuracy, and cannot support decision-making in patient populations with high prevalence of asymptomatic bacteriuria, such as older adults. Detecting biomarkers of host response in the urine of hosts has the potential to improve diagnosis. Objectives To synthesise the evidence of the diagnostic accuracy of novel biomarkers for UTI, and of their ability to differentiate UTI from asymptomatic bacteriuria. Design A systematic review. Data Sources and Methods We searched MEDLINE, EMBASE, CINAHL and Web of Science for studies of novel biomarkers for the diagnosis of UTI. We excluded studies assessing biomarkers included in urine dipsticks as these have been well described previously. We included studies of adult patients (≥16 years) with a suspected or confirmed urinary tract infection using microscopy and culture as the reference standard. We excluded studies using clinical signs and symptoms, or urine dipstick only as a reference standard. Quality appraisal was performed using QUADAS-2. We summarised our data using point estimates and data accuracy statistics. Results We included 37 studies on 4009 adults measuring 66 biomarkers. Study quality was limited by case-control design and study size; only 4 included studies had a prospective cohort design. IL-6 and IL-8 were the most studied biomarkers. We found plausible evidence to suggest that IL-8, IL-6, GRO-a, sTNF-1, sTNF-2 and MCR may benefit from more rigorous evaluation of their potential diagnostic value for UTI. Conclusions There is insufficient evidence to recommend the use of any novel biomarker for UTI diagnosis at present. Further evaluation of the more promising candidates, is needed before they can be recommended for clinical use.
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Affiliation(s)
- George Edwards
- NIHR Community Healthcare Medtech and IVD Cooperative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK,George Edwards, Nuffield Department of Primary Care Health Sciences, University of Oxford, Woodstock Road, Oxford OX2 6GG, UK.
| | - Anna Seeley
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Adam Carter
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Maia Patrick Smith
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Elizabeth LA Cross
- Department of Global Health and Infection, Brighton and Sussex Medical School, Falmer, UK
| | - Kathryn Hughes
- PRIME Centre Wales, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Ann Van den Bruel
- EPI-Centre, Academic Centre for General Practice, KU Leuven, Leuven, Belgium
| | - Martin J Llewelyn
- Department of Global Health and Infection, Brighton and Sussex Medical School, Falmer, UK
| | - Jan Y Verbakel
- NIHR Community Healthcare Medtech and IVD Cooperative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK,EPI-Centre, Academic Centre for General Practice, KU Leuven, Leuven, Belgium
| | - Gail Hayward
- NIHR Community Healthcare Medtech and IVD Cooperative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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8
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Yokoyama M, Peto L, Budgell EP, Jones N, Sheridan E, Liu J, Walker AS, Stoesser N, Gweon HS, Llewelyn MJ. Microbial diversity and antimicrobial resistance in faecal samples from acute medical patients assessed through metagenomic sequencing. PLoS One 2023; 18:e0282584. [PMID: 36928667 PMCID: PMC10019653 DOI: 10.1371/journal.pone.0282584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 02/18/2023] [Indexed: 03/18/2023] Open
Abstract
Antimicrobial resistance (AMR) is a threat to global public health. However, unsatisfactory approaches to directly measuring the AMR burden carried by individuals has hampered efforts to assess interventions aimed at reducing selection for AMR. Metagenomics can provide accurate detection and quantification of AMR genes within an individual person's faecal flora (their gut "resistome"). Using this approach, we aimed to test the hypothesis that differences in antimicrobial use across different hospitals in the United Kingdom will result in observable differences in the resistome of individual patients. Three National Health Service acute Hospital Trusts with markedly different antibiotic use and Clostridioides difficile infection rates collected faecal samples from anonymous patients which were discarded after C. difficile testing over a period of 9 to 15 months. Metagenomic DNA was extracted from these samples and sequenced using an Illumina NovaSeq 6000 platform. The resulting sequencing reads were analysed for taxonomic composition and for the presence of AMR genes. Among 683 faecal metagenomes we found huge variation between individuals in terms of taxonomic diversity (Shannon Index range 0.10-3.99) and carriage of AMR genes (Median 1.50 genes/cell/sample overall). We found no statistically significant differences in diversity (median Shannon index 2.16 (IQR 1.71-2.56), 2.15 (IQR 1.62-2.50) and 2.26 (IQR 1.55-2.51)) or carriage of AMR genes (median 1.37 genes/cell/sample (IQR 0.70-3.24), 1.70 (IQR 0.70-4.52) and 1.43 (IQR 0.55-3.71)) at the three trusts respectively. This was also the case across the sample collection period within the trusts. While we have not demonstrated differences over place or time using metagenomic sequencing of faecal discards, other sampling frameworks may be more suitable to determine whether organisational level differences in antibiotic use are associated with individual-level differences in burden of AMR carriage.
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Affiliation(s)
- Maho Yokoyama
- Department of Global Health and Infectious Diseases, Brighton and Sussex Medical School, Brighton, United Kingdom
| | - Leon Peto
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Eric P Budgell
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Nicola Jones
- Department of Infection, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Elizabeth Sheridan
- Department of Microbiology, University Hospitals Dorset, Bournemouth, United Kingdom
| | - Jane Liu
- Department of Microbiology, Royal United Hospitals Bath, Bath, United Kingdom
| | - A Sarah Walker
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Nicole Stoesser
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Department of Infection, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Hyun S Gweon
- School of Biological Sciences, University of Reading, Whiteknights, Reading, United Kingdom
- UK Centre for Ecology & Hydrology, Wallingford, Oxfordshire, United Kingdom
| | - Martin J Llewelyn
- Department of Global Health and Infectious Diseases, Brighton and Sussex Medical School, Brighton, United Kingdom
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9
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Llewelyn MJ, Price N, Ratnaraja N, Atkins B, Partridge D, Jeffery K. Where now for infection services in the NHS? How lessons from the pandemic should drive long-overdue integration of microbiology and infectious diseases. Clin Med (Lond) 2022; 22:586-589. [PMID: 38589168 PMCID: PMC9761420 DOI: 10.7861/clinmed.2022-0251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
In its first 2 decades, the NHS witnessed the near eradication of life-threatening community-acquired infections. However, medical advances have created different challenges (such as antimicrobial resistance and healthcare-associated infections) against a background of an increasingly ageing population. The recent COVID-19 pandemic has highlighted a lack of parity with regards to provision of NHS 'infection services' (infectious diseases, microbiology and virology) across the UK, which urgently needs to be addressed. We recommend a fundamental review of NHS infection service provision: divided into four key areas. Firstly, there should be a consideration of a single multidisciplinary specialty of infection medicine removing barriers to training and service delivery. Secondly, streamline infection training via a single pathway through to certificate of completion of training, encompassing all aspects of infection service provision, for example, infection diagnostics, clinical care (including inpatient, outpatient and community based care), and infection prevention and control. There should be flexibility within the training curriculum to facilitate combined training with general internal medicine (GIM) as well as out of programme activities. Innovative ways of providing clinical experience should be considered, acknowledging the roles that medical microbiologists working closely with GIM colleagues in district general hospitals can play in managing patients with infections. Thirdly, formally commission a national network of specialised infectious diseases units with the creation of service standards. This can facilitate future pandemic resilience using a hub-and-spoke model utilising local infection expertise. Lastly, standardise the NHS framework to lead and coordinate development of integrated infection services at the local level.
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Affiliation(s)
- Martin J Llewelyn
- University of Sussex, Falmer, UK and consultant in infection, University Hospitals Sussex NHS Foundation Trust, Brighton, UK.
| | | | - Natasha Ratnaraja
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Bridget Atkins
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - David Partridge
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK and honorary senior clinical lecturer, Florey Institute for Host-Pathogen Interaction, Sheffield, UK
| | - Katie Jeffery
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK and associate professor of microbiology and hospital epidemiology, University of Oxford, Oxford, UK
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10
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Llewelyn MJ, West RM, Carrol ED, Pallmann P, Sandoe JAT. Impact of introducing procalcitonin testing on antibiotic usage in acute NHS hospitals during the first wave of COVID-19 in the UK: a controlled interrupted time series analysis of organization-level data-authors' response. J Antimicrob Chemother 2022; 77:3211-3212. [PMID: 36124922 PMCID: PMC9494444 DOI: 10.1093/jac/dkac315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
| | - Robert M West
- School of Medicine, University of Leeds, Worsley Building, Clarendon Way, Leeds LS2 9LU, UK
| | - Enitan D Carrol
- Department of Clinical Infection, Microbiology and Immunology, University of Liverpool Institute of Infection, Veterinary and Ecological Sciences, Ronald Ross Building, 8 West Derby Street, Liverpool L69 7BE, UK
| | - Philip Pallmann
- Centre for Trials Research, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff CF14 4YS, UK
| | - Jonathan A T Sandoe
- Department of Microbiology, The Old Medical School, The General Infirmary at Leeds, Leeds LS1 3EX, UK
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11
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McBride A, Vuong NL, Van Hao N, Huy NQ, Chanh HQ, Chau NTX, Nguyet NM, Ming DK, Ngoc NT, Nhat PTH, Phong NT, Tai LTH, Tho PV, Trung DT, Tam DTH, Trieu HT, Geskus RB, Llewelyn MJ, Thwaites CL, Yacoub S. A modified Sequential Organ Failure Assessment score for dengue: development, evaluation and proposal for use in clinical trials. BMC Infect Dis 2022; 22:722. [PMID: 36057771 PMCID: PMC9441074 DOI: 10.1186/s12879-022-07705-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 08/23/2022] [Indexed: 11/19/2022] Open
Abstract
Background Dengue is a neglected tropical disease, for which no therapeutic agents have shown clinical efficacy to date. Clinical trials have used strikingly variable clinical endpoints, which hampers reproducibility and comparability of findings. We investigated a delta modified Sequential Organ Failure Assessment (delta mSOFA) score as a uniform composite clinical endpoint for use in clinical trials investigating therapeutics for moderate and severe dengue. Methods We developed a modified SOFA score for dengue, measured and evaluated its performance at baseline and 48 h after enrolment in a prospective observational cohort of 124 adults admitted to a tertiary referral hospital in Vietnam with dengue shock. The modified SOFA score included pulse pressure in the cardiovascular component. Binary logistic regression, cox proportional hazard and linear regression models were used to estimate association between mSOFA, delta mSOFA and clinical outcomes. Results The analysis included 124 adults with dengue shock. 29 (23.4%) patients required ICU admission for organ support or due to persistent haemodynamic instability: 9/124 (7.3%) required mechanical ventilation, 8/124 (6.5%) required vasopressors, 6/124 (4.8%) required haemofiltration and 5/124 (4.0%) patients died. In univariate analyses, higher baseline and delta (48 h) mSOFA score for dengue were associated with admission to ICU, requirement for organ support and mortality, duration of ICU and hospital admission and IV fluid use. Conclusions The baseline and delta mSOFA scores for dengue performed well to discriminate patients with dengue shock by clinical outcomes, including duration of ICU and hospital admission, requirement for organ support and death. We plan to use delta mSOFA as the primary endpoint in an upcoming host-directed therapeutic trial and investigate the performance of this score in other phenotypes of severe dengue in adults and children. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-022-07705-8.
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Affiliation(s)
- Angela McBride
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton, UK
| | - Nguyen Lam Vuong
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Nguyen Van Hao
- Hospital for Tropical Disease, Ho Chi Minh City, Vietnam
| | - Nguyen Quang Huy
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Ho Quang Chanh
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | | | - Damien K Ming
- Department of Infectious Disease, Imperial College London, London, UK
| | | | | | | | | | - Phan Vinh Tho
- Hospital for Tropical Disease, Ho Chi Minh City, Vietnam
| | - Dinh The Trung
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | | | - Ronald Bertus Geskus
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Martin J Llewelyn
- Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton, UK
| | - C Louise Thwaites
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Sophie Yacoub
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam. .,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.
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12
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Munro APS, Feng S, Janani L, Cornelius V, Aley PK, Babbage G, Baxter D, Bula M, Cathie K, Chatterjee K, Dodd K, Enever Y, Qureshi E, Goodman AL, Green CA, Harndahl L, Haughney J, Hicks A, van der Klaauw AA, Kanji N, Libri V, Llewelyn MJ, McGregor AC, Maallah M, Minassian AM, Moore P, Mughal M, Mujadidi YF, Holliday K, Osanlou O, Osanlou R, Owens DR, Pacurar M, Palfreeman A, Pan D, Rampling T, Regan K, Saich S, Bawa T, Saralaya D, Sharma S, Sheridan R, Thomson EC, Todd S, Twelves C, Read RC, Charlton S, Hallis B, Ramsay M, Andrews N, Lambe T, Nguyen-Van-Tam JS, Snape MD, Liu X, Faust SN, Feng S, Janani L, Cornelius V, Aley PK, Babbage G, Baxter D, Bula M, Cathie K, Chatterjee K, Dodd K, Enever Y, Qureshi E, Goodman AL, Green CA, Harndahl L, Haughney J, Hicks A, van der Klaauw AA, Kanji N, Libri V, Llewelyn MJ, McGregor AC, Minassian AM, Moore P, Mughal M, Mujadidi YF, Holliday K, Osanlou O, Osanlou R, Owens DR, Pacurar M, Palfreeman A, Pan D, Rampling T, Regan K, Saich S, Bawa T, Saralaya D, Sharma S, Sheridan R, Maallah M, Thomson EC, Todd S, Twelves C, Read RC, Charlton S, Hallis B, Ramsay M, Andrews N, Lambe T, Nguyen-Van-Tam JS, Snape MD, Liu X, Faust SN, Riordan A, Ustianowski A, Rogers C, Katechia K, Cooper A, Freedman A, Hughes R, Grundy L, Tudor Jones L, Harrison E, Snashall E, Mallon L, Burton K, Storton K, Munusamy M, Tandy B, Egbo A, Cox S, Ahmed NN, Shenoy A, Bousfield R, Wixted D, Gutteridge H, Mansfield B, Herbert C, Murira J, Calderwood J, Barker D, Brandon J, Tulloch H, Colquhoun S, Thorp H, Radford H, Evans J, Baker H, Thorpe J, Batham S, Hailstone J, Phillips R, Kumar D, Westwell F, Sturdy A, Barcella L, Soussi N, Mpelembue M, Raj S, Sharma R, Corrah T, John L, Whittington A, Roche S, Wagstaff L, Farrier A, Bisnauthsing K, Abeywickrama M, Spence N, Packham A, Serafimova T, Aslam S, McGreevy C, Borca A, DeLosSantosDominguez P, Palmer E, Broadhead S, Farooqi S, Piper J, Weighell R, Pickup L, Shamtally D, Domingo J, Kourampa E, Hale C, Gibney J, Stackpoole M, Rashid-Gardner Z, Lyon R, McDonnell C, Cole C, Stewart A, McMillan G, Savage M, Beckett H, Moorbey C, Desai A, Brown C, Naker K, Gokani K, Trinham C, Sabine C, Moore S, Hurdover S, Justice E, Stone M, Plested E, Ferreira Da Silva C, White R, Robinson H, Turnbull I, Morshead G, Drake-Brockman R, Smith C, Li G, Kasanyinga M, Clutterbuck EA, Bibi S, Singh M, Champaneri T, Irwin M, Khan M, Kownacka A, Nabunjo M, Osuji C, Hladkiwskyj J, Galvin D, Patel G, Grierson J, Males S, Askoolam K, Barry J, Mouland J, Longhurst B, Moon M, Giddins B, Pereira Dias Alves C, Richmond L, Minnis C, Baryschpolec S, Elliott S, Fox L, Graham V, Baker N, Godwin K, Buttigieg K, Knight C, Brown P, Lall P, Shaik I, Chiplin E, Brunt E, Leung S, Allen L, Thomas S, Fraser S, Choi B, Gouriet J, Perkins J, Gowland A, Macdonald J, Seenan JP, Starinskij I, Seaton A, Peters E, Singh S, Gardside B, Bonnaud A, Davies C, Gordon E, Keenan S, Hall J, Wilkins S, Tasker S, James R, Seath I, Littlewood K, Newman J, Boubriak I, Suggitt D, Haydock H, Bennett S, Woodyatt W, Hughes K, Bell J, Coughlan T, van Welsenes D, Kamal M, Cooper C, Tunstall S, Ronan N, Cutts R, Dare T, Yim YTN, Whittley S, Hamal S, Ricamara M, Adams K, Baker H, Driver K, Turner N, Rawlins T, Roy S, Merida-Morillas M, Sakagami Y, Andrews A, Goncalvescordeiro L, Stokes M, Ambihapathy W, Spencer J, Parungao N, Berry L, Cullinane J, Presland L, Ross Russell A, Warren S, Baker J, Oliver A, Buadi A, Lee K, Haskell L, Romani R, Bentley I, Whitbred T, Fowler S, Gavin J, Magee A, Watson T, Nightingale K, Marius P, Summerton E, Locke E, Honey T, Lingwood A, de la Haye A, Elliott RS, Underwood K, King M, Davies-Dear S, Horsfall E, Chalwin O, Burton H, Edwards CJ, Welham B, Appleby K, Dineen E, Garrahy S, Hall F, Ladikou E, Mullan D, Hansen D, Campbell M, Dos Santos F, Lakeman N, Branney D, Vamplew L, Hogan A, Frankham J, Wiselka M, Vail D, Wenn V, Renals V, Ellis K, Lewis-Taylor J, Habash-Bailey H, Magan J, Hardy A. Safety, immunogenicity, and reactogenicity of BNT162b2 and mRNA-1273 COVID-19 vaccines given as fourth-dose boosters following two doses of ChAdOx1 nCoV-19 or BNT162b2 and a third dose of BNT162b2 (COV-BOOST): a multicentre, blinded, phase 2, randomised trial. Lancet Infect Dis 2022; 22:1131-1141. [PMID: 35550261 PMCID: PMC9084623 DOI: 10.1016/s1473-3099(22)00271-7] [Citation(s) in RCA: 81] [Impact Index Per Article: 40.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 04/19/2022] [Accepted: 04/19/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Some high-income countries have deployed fourth doses of COVID-19 vaccines, but the clinical need, effectiveness, timing, and dose of a fourth dose remain uncertain. We aimed to investigate the safety, reactogenicity, and immunogenicity of fourth-dose boosters against COVID-19. METHODS The COV-BOOST trial is a multicentre, blinded, phase 2, randomised controlled trial of seven COVID-19 vaccines given as third-dose boosters at 18 sites in the UK. This sub-study enrolled participants who had received BNT162b2 (Pfizer-BioNTech) as their third dose in COV-BOOST and randomly assigned them (1:1) to receive a fourth dose of either BNT162b2 (30 μg in 0·30 mL; full dose) or mRNA-1273 (Moderna; 50 μg in 0·25 mL; half dose) via intramuscular injection into the upper arm. The computer-generated randomisation list was created by the study statisticians with random block sizes of two or four. Participants and all study staff not delivering the vaccines were masked to treatment allocation. The coprimary outcomes were safety and reactogenicity, and immunogenicity (anti-spike protein IgG titres by ELISA and cellular immune response by ELISpot). We compared immunogenicity at 28 days after the third dose versus 14 days after the fourth dose and at day 0 versus day 14 relative to the fourth dose. Safety and reactogenicity were assessed in the per-protocol population, which comprised all participants who received a fourth-dose booster regardless of their SARS-CoV-2 serostatus. Immunogenicity was primarily analysed in a modified intention-to-treat population comprising seronegative participants who had received a fourth-dose booster and had available endpoint data. This trial is registered with ISRCTN, 73765130, and is ongoing. FINDINGS Between Jan 11 and Jan 25, 2022, 166 participants were screened, randomly assigned, and received either full-dose BNT162b2 (n=83) or half-dose mRNA-1273 (n=83) as a fourth dose. The median age of these participants was 70·1 years (IQR 51·6-77·5) and 86 (52%) of 166 participants were female and 80 (48%) were male. The median interval between the third and fourth doses was 208·5 days (IQR 203·3-214·8). Pain was the most common local solicited adverse event and fatigue was the most common systemic solicited adverse event after BNT162b2 or mRNA-1273 booster doses. None of three serious adverse events reported after a fourth dose with BNT162b2 were related to the study vaccine. In the BNT162b2 group, geometric mean anti-spike protein IgG concentration at day 28 after the third dose was 23 325 ELISA laboratory units (ELU)/mL (95% CI 20 030-27 162), which increased to 37 460 ELU/mL (31 996-43 857) at day 14 after the fourth dose, representing a significant fold change (geometric mean 1·59, 95% CI 1·41-1·78). There was a significant increase in geometric mean anti-spike protein IgG concentration from 28 days after the third dose (25 317 ELU/mL, 95% CI 20 996-30 528) to 14 days after a fourth dose of mRNA-1273 (54 936 ELU/mL, 46 826-64 452), with a geometric mean fold change of 2·19 (1·90-2·52). The fold changes in anti-spike protein IgG titres from before (day 0) to after (day 14) the fourth dose were 12·19 (95% CI 10·37-14·32) and 15·90 (12·92-19·58) in the BNT162b2 and mRNA-1273 groups, respectively. T-cell responses were also boosted after the fourth dose (eg, the fold changes for the wild-type variant from before to after the fourth dose were 7·32 [95% CI 3·24-16·54] in the BNT162b2 group and 6·22 [3·90-9·92] in the mRNA-1273 group). INTERPRETATION Fourth-dose COVID-19 mRNA booster vaccines are well tolerated and boost cellular and humoral immunity. Peak responses after the fourth dose were similar to, and possibly better than, peak responses after the third dose. FUNDING UK Vaccine Task Force and National Institute for Health Research.
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Affiliation(s)
- Alasdair P S Munro
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Shuo Feng
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Leila Janani
- Imperial Clinical Trials Unit, Imperial College London, London, UK
| | | | - Parvinder K Aley
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Gavin Babbage
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Marcin Bula
- NIHR Liverpool and Broadgreen Clinical Research Facility, Liverpool, UK
| | - Katrina Cathie
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Krishna Chatterjee
- NIHR Cambridge Clinical Research Facility, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Kate Dodd
- NIHR Liverpool and Broadgreen Clinical Research Facility, Liverpool, UK
| | | | - Ehsaan Qureshi
- NIHR/Wellcome Clinical Research Facility, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Anna L Goodman
- Department of Infection, Guy's and St Thomas' NHS Foundation Trust, London, UK; MRC Clinical Trials Unit, University College London, London, UK
| | - Christopher A Green
- NIHR/Wellcome Clinical Research Facility, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Linda Harndahl
- Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - John Haughney
- Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Alexander Hicks
- Wellcome-MRC Institute of Metabolic Science, Department of Clinical Biochemistry, University of Cambridge, Cambridge, UK
| | - Agatha A van der Klaauw
- Wellcome-MRC Institute of Metabolic Science, Department of Clinical Biochemistry, University of Cambridge, Cambridge, UK
| | - Nasir Kanji
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Vincenzo Libri
- NIHR UCLH Clinical Research Facility and NIHR UCLH Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Alastair C McGregor
- Department of Infectious Diseases and Tropical Medicine, London Northwest University Healthcare, London, UK
| | - Mina Maallah
- Department of Infectious Diseases and Tropical Medicine, London Northwest University Healthcare, London, UK
| | - Angela M Minassian
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; Jenner Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | | | | | - Kyra Holliday
- NIHR Leeds Clinical Research Facility, Leeds Teaching Hospitals Trust and University of Leeds, Leeds, UK
| | - Orod Osanlou
- Public Health Wales, Betsi Cadwaladr University Health Board, Bangor University, Bangor, UK
| | | | - Daniel R Owens
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Mihaela Pacurar
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Adrian Palfreeman
- University Hospitals of Leicester NHS Trust, University of Leicester, Leicester, UK
| | - Daniel Pan
- University Hospitals of Leicester NHS Trust, University of Leicester, Leicester, UK
| | - Tommy Rampling
- NIHR UCLH Clinical Research Facility and NIHR UCLH Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK
| | - Karen Regan
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Stephen Saich
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Tanveer Bawa
- Department of Infection, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Dinesh Saralaya
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Sunil Sharma
- University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Ray Sheridan
- Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, UK
| | - Emma C Thomson
- Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK; MRC-University of Glasgow Centre for Virus Research, Glasgow, UK
| | - Shirley Todd
- Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, UK
| | - Chris Twelves
- NIHR Leeds Clinical Research Facility, Leeds Teaching Hospitals Trust and University of Leeds, Leeds, UK
| | - Robert C Read
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Sue Charlton
- UK Health Security Agency, Porton Down, Porton, UK
| | | | - Mary Ramsay
- UK Health Security Agency, Colindale, London, UK
| | - Nick Andrews
- UK Health Security Agency, Colindale, London, UK
| | - Teresa Lambe
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Jonathan S Nguyen-Van-Tam
- Division of Epidemiology and Public Health, University of Nottingham School of Medicine, University of Nottingham, Nottingham, UK
| | - Matthew D Snape
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Xinxue Liu
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Saul N Faust
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK.
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Liu X, Munro APS, Feng S, Janani L, Aley PK, Babbage G, Baxter D, Bula M, Cathie K, Chatterjee K, Dejnirattisai W, Dodd K, Enever Y, Qureshi E, Goodman AL, Green CA, Harndahl L, Haughney J, Hicks A, van der Klaauw AA, Kwok J, Libri V, Llewelyn MJ, McGregor AC, Minassian AM, Moore P, Mughal M, Mujadidi YF, Holliday K, Osanlou O, Osanlou R, Owens DR, Pacurar M, Palfreeman A, Pan D, Rampling T, Regan K, Saich S, Serafimova T, Saralaya D, Screaton GR, Sharma S, Sheridan R, Sturdy A, Supasa P, Thomson EC, Todd S, Twelves C, Read RC, Charlton S, Hallis B, Ramsay M, Andrews N, Lambe T, Nguyen-Van-Tam JS, Cornelius V, Snape MD, Faust SN. Persistence of immunogenicity after seven COVID-19 vaccines given as third dose boosters following two doses of ChAdOx1 nCov-19 or BNT162b2 in the UK: Three month analyses of the COV-BOOST trial. J Infect 2022; 84:795-813. [PMID: 35405168 PMCID: PMC8993491 DOI: 10.1016/j.jinf.2022.04.018] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 04/04/2022] [Accepted: 04/05/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVES To evaluate the persistence of immunogenicity three months after third dose boosters. METHODS COV-BOOST is a multicentre, randomised, controlled, phase 2 trial of seven COVID-19 vaccines used as a third booster dose. The analysis was conducted using all randomised participants who were SARS-CoV-2 naïve during the study. RESULTS Amongst the 2883 participants randomised, there were 2422 SARS-CoV-2 naïve participants until D84 visit included in the analysis with median age of 70 (IQR: 30-94) years. In the participants who had two initial doses of ChAdOx1 nCov-19 (Oxford-AstraZeneca; hereafter referred to as ChAd), schedules using mRNA vaccines as third dose have the highest anti-spike IgG at D84 (e.g. geometric mean concentration of 8674 ELU/ml (95% CI: 7461-10,085) following ChAd/ChAd/BNT162b2 (Pfizer-BioNtech, hearafter referred to as BNT)). However, in people who had two initial doses of BNT there was no significant difference at D84 in people given ChAd versus BNT (geometric mean ratio (GMR) of 0.95 (95%CI: 0.78, 1.15). Also, people given Ad26.COV2.S (Janssen; hereafter referred to as Ad26) as a third dose had significantly higher anti-spike IgG at D84 than BNT (GMR of 1.20, 95%CI: 1.01,1.43). Responses at D84 between people who received BNT (15 μg) or BNT (30 μg) after ChAd/ChAd or BNT/BNT were similar, with anti-spike IgG GMRs of half-BNT (15 μg) versus BNT (30 μg) ranging between 0.74-0.86. The decay rate of cellular responses were similar between all the vaccine schedules and doses. CONCLUSIONS 84 days after a third dose of COVID-19 vaccine the decay rates of humoral response were different between vaccines. Adenoviral vector vaccine anti-spike IgG concentrations at D84 following BNT/BNT initial doses were similar to or even higher than for a three dose (BNT/BNT/BNT) schedule. Half dose BNT immune responses were similar to full dose responses. While high antibody tires are desirable in situations of high transmission of new variants of concern, the maintenance of immune responses that confer long-lasting protection against severe disease or death is also of critical importance. Policymakers may also consider adenoviral vector, fractional dose of mRNA, or other non-mRNA vaccines as third doses.
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Affiliation(s)
- Xinxue Liu
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK.
| | - Alasdair P S Munro
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Shuo Feng
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Leila Janani
- Imperial Clinical Trials Unit, Imperial College London, London, UK
| | - Parvinder K Aley
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Gavin Babbage
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Marcin Bula
- NIHR Liverpool and Broadgreen Clinical Research Facility, Liverpool, UK
| | - Katrina Cathie
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Krishna Chatterjee
- NIHR Cambridge Clinical Research Facility, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Wanwisa Dejnirattisai
- Wellcome Centre for Human Genetics, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Kate Dodd
- NIHR Liverpool and Broadgreen Clinical Research Facility, Liverpool, UK
| | | | - Ehsaan Qureshi
- NIHR/Wellcome Clinical Research Facility, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Anna L Goodman
- Department of Infection, Guy's and St Thomas' NHS Foundation Trust, London, UK; MRC Clinical Trials Unit, University College London, London, UK
| | - Christopher A Green
- NIHR/Wellcome Clinical Research Facility, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Linda Harndahl
- Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - John Haughney
- Queen Elizabeth University Hospital, NHS Greater Glasgow & Clyde, Glasgow, UK
| | | | - Agatha A van der Klaauw
- Wellcome-MRC Institute of Metabolic Science, Department of Clinical Biochemistry, University of Cambridge, Cambridge, UK
| | - Jonathan Kwok
- Cancer Research UK Oxford Centre, University of Oxford, Oxford, UK
| | - Vincenzo Libri
- NIHR UCLH Clinical Research Facility and NIHR UCLH Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Alastair C McGregor
- Department of Infectious Diseases and Tropical Medicine, London Northwest University Healthcare, London, UK
| | - Angela M Minassian
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; Jenner Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | | | | | - Kyra Holliday
- NIHR Leeds Clinical Research Facility, Leeds Teaching Hospitals Trust and University of Leeds, Leeds, UK
| | - Orod Osanlou
- Public Health Wales, Betsi Cadwaladr University Health Board, Bangor University, Bangor, UK
| | | | - Daniel R Owens
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Mihaela Pacurar
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Adrian Palfreeman
- University Hospitals of Leicester NHS Trust, University of Leicester, Leicester, UK
| | - Daniel Pan
- University Hospitals of Leicester NHS Trust, University of Leicester, Leicester, UK
| | - Tommy Rampling
- NIHR UCLH Clinical Research Facility and NIHR UCLH Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK
| | - Karen Regan
- Bradford Institute for Health Research and Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Stephen Saich
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Teona Serafimova
- Department of Infection, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Dinesh Saralaya
- Bradford Institute for Health Research and Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Gavin R Screaton
- Wellcome Centre for Human Genetics, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Sunil Sharma
- University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Ray Sheridan
- Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, UK
| | - Ann Sturdy
- Department of Infectious Diseases and Tropical Medicine, London Northwest University Healthcare, London, UK
| | - Piyada Supasa
- Wellcome Centre for Human Genetics, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Emma C Thomson
- Queen Elizabeth University Hospital, NHS Greater Glasgow & Clyde, Glasgow, UK; MRC University of Glasgow Centre for Virus Research, Glasgow, UK
| | - Shirley Todd
- Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, UK
| | - Chris Twelves
- NIHR Leeds Clinical Research Facility, Leeds Teaching Hospitals Trust and University of Leeds, Leeds, UK
| | - Robert C Read
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | | | | | - Mary Ramsay
- UK Health Security Agency, Colindale, London, UK
| | - Nick Andrews
- UK Health Security Agency, Colindale, London, UK
| | - Teresa Lambe
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | | | | | - Matthew D Snape
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Saul N Faust
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK.
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Camp J, Filla T, Glaubitz L, Kaasch AJ, Fuchs F, Scarborough M, Kim HB, Tilley R, Liao CH, Edgeworth J, Nsutebu E, López-Cortés LE, Morata L, Llewelyn MJ, Fowler VG, Thwaites G, Seifert H, Kern WV, Rieg S. Impact of neutropenia on clinical manifestations and outcome of Staphylococcus aureus bloodstream infection - A propensity score-based overlap weight analysis in two large, prospectively evaluated cohorts. Clin Microbiol Infect 2022; 28:1149.e1-1149.e9. [PMID: 35339677 DOI: 10.1016/j.cmi.2022.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 03/08/2022] [Accepted: 03/12/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To investigate whether neutropenia influenced mortality and long-term outcome of Staphylococcus aureus bloodstream infection (SAB). METHODS Data from two prospective, multicentre cohort studies (INSTINCT and ISAC) conducted in 20 tertiary care hospitals in 6 countries between 2006 and 2015 were analysed. Neutropenic and severely neutropenic patients (defined by the proxy of total white blood cell count <1000/μl and <500/μl, respectively, at onset of SAB) were compared to a control group using a propensity score model and overlap weights to adjust for baseline characteristics. Overall survival and time to SAB-related late complications (SAB recurrence, infective endocarditis, osteomyelitis, or other deep-seated manifestations) were analysed by Cox regression and competing risk analyses, respectively. RESULTS Of 3,187 patients, 102 were neutropenic and 70 were severely neutropenic at onset of SAB. Applying overlap weights yielded two groups of 83 neutropenic and 220 non-neutropenic patients, respectively. Baseline characteristics of these groups were exactly balanced. In the Cox regression analysis, we observed no significant difference in survival between the two groups (death during follow-up: 36.1 % in neutropenic vs. 30.6 % in non-neutropenic patients, hazard ratio 1.21 (95 % CI 0.79-1.83)). This finding remained unchanged when we considered severely neutropenic patients (hazard ratio 1.08 [0.60; 1.94]). Competing risk analysis showed a cause-specific hazard ratio (CSHR) of 0.39 (95 % CI 0.11-1.39) for SAB-related late-complications in neutropenic patients. CONCLUSIONS Neutropenia was not associated with a higher survival during follow-up. The lower rate of SAB-related late complications in neutropenic patients should be validated in other cohorts.
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Affiliation(s)
- Johannes Camp
- Division of Infectious Diseases, Department of Medicine II, Medical Centre-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Tim Filla
- Institute of Medical Biometry and Bioinformatics, Faculty of Medicine, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Lina Glaubitz
- Institute for Occupational, Social and Environmental Medicine, Centre for Health and Society, Faculty of Medicine, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Achim J Kaasch
- Institute of Medical Microbiology and Hospital Hygiene, University Hospital, Faculty of Medicine, Otto-von-Guericke-University Magdeburg, Magdeburg
| | - Frieder Fuchs
- Institute for Medical Microbiology, Immunology and Hygiene, University of Cologne, Medical Faculty and University Hospital of Cologne, Cologne, Germany
| | - Matt Scarborough
- Nuffield Department of Medicine, Oxford University Hospitals NHS Foundation, Oxford, UK
| | - Hong Bin Kim
- Division of Infectious Diseases, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Republic of Korea
| | - Robert Tilley
- Department of Microbiology, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Chun-Hsing Liao
- Infectious Diseases, Department of Internal Medicine, Far Eastern Memorial Hospital, Taiwan
| | - Jonathan Edgeworth
- Centre for Clinical Infection and Diagnostics Research, Department of Infectious Diseases, Kings College London & Guy's and St. Thomas' Hospitals NHS Foundation Trust, London, UK
| | - Emmanuel Nsutebu
- Tropical & Infectious Disease Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Luis Eduardo López-Cortés
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena, Sevilla, SpainInstituto de Biomedicina de Sevilla/Departamento de Medicina, Universidad de Sevilla/CSIC, Sevilla, Spain; Centro de Investigación Biomédica en Red en Enfermedades Infecciosas, Madrid, Spain
| | - Laura Morata
- Service of Infectious Diseases, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Martin J Llewelyn
- Department of Infectious Diseases and Microbiology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Vance G Fowler
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Guy Thwaites
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, UK; Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
| | - Harald Seifert
- Institute for Medical Microbiology, Immunology and Hygiene, University of Cologne, Medical Faculty and University Hospital of Cologne, Cologne, Germany
| | - Winfried V Kern
- Division of Infectious Diseases, Department of Medicine II, Medical Centre-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Siegbert Rieg
- Division of Infectious Diseases, Department of Medicine II, Medical Centre-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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15
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Euden J, Howard P, Powell N, Llewelyn MJ, Szakmany T, Albur M, Bond SE, Brookes-Howell L, Dark P, Hellyer TP, Hopkins S, McCullagh IJ, Ogden M, Pallmann P, Parsons H, Partridge DG, Shaw DE, Shinkins B, Todd S, Thomas-Jones E, West R, Carrol ED, Sandoe JAT. P14 Procalcitonin evaluation of antibiotic use in COVID-19 hospitalized patients during the first wave of COVID-19: the PEACH study. JAC Antimicrob Resist 2022. [PMCID: PMC9040064 DOI: 10.1093/jacamr/dlac004.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background A minority of patients presenting to hospital with COVID-19 have bacterial coinfection. Procalcitonin testing may help identify patients for whom antibiotics should be prescribed or withheld. The PEACH study describes the use of procalcitonin in English and Welsh hospitals during the first wave of the COVID-19 pandemic to help diagnose bacterial infections and guide antibiotic treatment. There is a lack of clear evidence to support its use in lung infections, which means in some hospitals, clinicians have used the procalcitonin test to guide antibiotic decisions in COVID-19, whilst in other hospitals, they have not. Our study is analysing data from hospitals that did and did not use procalcitonin testing during the first wave of the COVID-19 pandemic. It will determine whether and how procalcitonin testing should be used in the NHS in future waves of COVID-19 to protect patients from antibiotic overuse. Methods To assess whether the use of PCT testing, to guide antibiotic prescribing, safely reduced antibiotic use among patients who were hospitalized with COVID-19 during the first wave of the pandemic, we are answering this question through three different, and complimentary, work streams (WS), each with discrete work packages (WP): (i) Work Stream 1: utilization of PCT testing to guide antibiotic prescribing during the first wave of COVID-19 pandemic; (ii) Work Stream 2: patient-level impact of PCT testing on antibiotic exposure and clinical outcome (main work stream currently in analysis); and (iii) Work Stream 3: health economics analysis of PCT testing to guide antibiotics in COVID-19. Results Our first publication from Work Stream 1 (Antibiotics 2021, 10: 516) used a web-based survey to gather data from antimicrobial leads about the use of procalcitonin testing. Responses were received from 148/151 (98%) eligible hospitals. During the first wave of the COVID-19 pandemic, there was widespread introduction and expansion of PCT use in NHS hospitals. The number of hospitals using PCT in emergency/acute admissions rose from 17 (11%) to 74/146 (50.7%) and use in ICU increased from 70 (47.6%) to 124/147 (84.4%). This increase happened predominantly in March and April 2020, preceding NICE guidance. Approximately half of hospitals used PCT as a single test to guide decisions to discontinue antibiotics and half used repeated measurements. There was marked variation in the thresholds used for empirical antibiotic cessation and guidance about interpretation of values. Conclusions Procalcitonin testing has been widely adopted in the NHS during the COVID-19 pandemic in an unevidenced, heterogeneous way and in conflict with relevant NICE guidance. Further research is needed urgently that assesses the impact of this change on antibiotic prescribing and patient safety. Work Stream 2 is ongoing, and results will be published once available.
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Affiliation(s)
- Joanne Euden
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | | | | | | | - Tamas Szakmany
- The Grange University Hospital, Aneurin Bevan University Health Board, UK
| | | | | | | | - Paul Dark
- Manchester NIHR Biomedical Research Centre, University of Manchester, Manchester, UK
| | - Thomas P. Hellyer
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Iain J. McCullagh
- The Newcastle upon Tyne hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | | | - Helena Parsons
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - Dominick E. Shaw
- Division of Respiratory Medicine, University of Nottingham, Nottingham, UK
| | - Bethany Shinkins
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Stacy Todd
- Liverpool University Hospital NHS Foundation Trust, Liverpool, UK
| | | | - Robert West
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Enitan D. Carrol
- Institute of Infection, Veterinary & Ecological Sciences, University of Liverpool, Liverpool, UK
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16
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Hung TM, Van Hao N, Yen LM, McBride A, Dat VQ, van Doorn HR, Loan HT, Phong NT, Llewelyn MJ, Nadjm B, Yacoub S, Thwaites CL, Ahmed S, Van Vinh Chau N, Turner HC. Direct Medical Costs of Tetanus, Dengue, and Sepsis Patients in an Intensive Care Unit in Vietnam. Front Public Health 2022; 10:893200. [PMID: 35812512 PMCID: PMC9263973 DOI: 10.3389/fpubh.2022.893200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 05/13/2022] [Indexed: 11/27/2022] Open
Abstract
Background Critically ill patients often require complex clinical care by highly trained staff within a specialized intensive care unit (ICU) with advanced equipment. There are currently limited data on the costs of critical care in low-and middle-income countries (LMICs). This study aims to investigate the direct-medical costs of key infectious disease (tetanus, sepsis, and dengue) patients admitted to ICU in a hospital in Ho Chi Minh City (HCMC), Vietnam, and explores how the costs and cost drivers can vary between the different diseases. Methods We calculated the direct medical costs for patients requiring critical care for tetanus, dengue and sepsis. Costing data (stratified into different cost categories) were extracted from the bills of patients hospitalized to the adult ICU with a dengue, sepsis and tetanus diagnosis that were enrolled in three studies conducted at the Hospital for Tropical Diseases in HCMC from January 2017 to December 2019. The costs were considered from the health sector perspective. The total sample size in this study was 342 patients. Results ICU care was associated with significant direct medical costs. For patients that did not require mechanical ventilation, the median total ICU cost per patient varied between US$64.40 and US$675 for the different diseases. The costs were higher for patients that required mechanical ventilation, with the median total ICU cost per patient for the different diseases varying between US$2,590 and US$4,250. The main cost drivers varied according to disease and associated severity. Conclusion This study demonstrates the notable cost of ICU care in Vietnam and in similar LMIC settings. Future studies are needed to further evaluate the costs and economic burden incurred by ICU patients. The data also highlight the importance of evaluating novel critical care interventions that could reduce the costs of ICU care.
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Affiliation(s)
- Trinh Manh Hung
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Vietnam
| | - Nguyen Van Hao
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam.,Department of Infectious Diseases, University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
| | - Lam Minh Yen
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Vietnam
| | - Angela McBride
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Vietnam.,Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton, United Kingdom
| | - Vu Quoc Dat
- Department of Infectious Diseases, Hanoi Medical University, Hanoi, Vietnam
| | - H Rogier van Doorn
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Hanoi, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Huynh Thi Loan
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | | | - Martin J Llewelyn
- Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton, United Kingdom
| | - Behzad Nadjm
- Medical Research Council (MRC) Unit the Gambia at the London School of Hygiene & Tropical Medicine, Fajara, Gambia
| | - Sophie Yacoub
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - C Louise Thwaites
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Sayem Ahmed
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | | | - Hugo C Turner
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, Norfolk Place, London, United Kingdom
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17
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Llewelyn MJ, Grozeva D, Howard P, Euden J, Gerver SM, Hope R, Heginbothom M, Powell N, Richman C, Shaw D, Thomas-Jones E, West RM, Carrol ED, Pallmann P, Sandoe JAT. OUP accepted manuscript. J Antimicrob Chemother 2022; 77:1189-1196. [PMID: 35137110 PMCID: PMC9383456 DOI: 10.1093/jac/dkac017] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 01/06/2022] [Indexed: 01/08/2023] Open
Abstract
Background Blood biomarkers have the potential to help identify COVID-19 patients with bacterial coinfection in whom antibiotics are indicated. During the COVID-19 pandemic, procalcitonin testing was widely introduced at hospitals in the UK to guide antibiotic prescribing. We have determined the impact of this on hospital-level antibiotic consumption. Methods We conducted a retrospective, controlled interrupted time series analysis of organization-level data describing antibiotic dispensing, hospital activity and procalcitonin testing for acute hospitals/hospital trusts in England and Wales during the first wave of COVID-19 (24 February to 5 July 2020). Results In the main analysis of 105 hospitals in England, introduction of procalcitonin testing in emergency departments/acute medical admission units was associated with a statistically significant decrease in total antibiotic use of −1.08 (95% CI: −1.81 to −0.36) DDDs of antibiotic per admission per week per trust. This effect was then lost at a rate of 0.05 (95% CI: 0.02–0.08) DDDs per admission per week. Similar results were found specifically for first-line antibiotics for community-acquired pneumonia and for COVID-19 admissions rather than all admissions. Introduction of procalcitonin in the ICU setting was not associated with any significant change in antibiotic use. Conclusions At hospitals where procalcitonin testing was introduced in emergency departments/acute medical units this was associated with an initial, but unsustained, reduction in antibiotic use. Further research should establish the patient-level impact of procalcitonin testing in this population and understand its potential for clinical effectiveness.
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Affiliation(s)
- Martin J. Llewelyn
- Global Health and Infectious Diseases, Brighton and Sussex Medical School, University of Sussex, Brighton, BN1 9PS, UK
- Department of Microbiology and Infection, University Hospitals Sussex NHS Foundation Trust, Brighton, BN2 5BE, UK
- Corresponding author. E-mail:
| | - Detelina Grozeva
- Centre for Trials Research, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS, UK
| | - Philip Howard
- School of Healthcare, University of Leeds, Leeds, LS2 9JT, UK
- Pharmacy Department, Leeds Teaching Hospitals, Leeds, LS1 3EX, UK
| | - Joanne Euden
- Centre for Trials Research, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS, UK
| | - Sarah M. Gerver
- Division of Healthcare Associated Infections and Antimicrobial Resistance, National Infection Service, Public Health England, 61 Colindale Avenue, London, NW9 5EQ, UK
| | - Russell Hope
- Division of Healthcare Associated Infections and Antimicrobial Resistance, National Infection Service, Public Health England, 61 Colindale Avenue, London, NW9 5EQ, UK
| | - Margaret Heginbothom
- Healthcare Associated Infection, Antimicrobial Resistance and Prescribing Programme, Public Health Wales, 2 Capital Quarter, Tyndall St, Cardiff, CF10 4BZ, UK
| | - Neil Powell
- Pharmacy Department, Royal Cornwall Hospital Trust, Truro, TR1 3LJ, UK
| | - Colin Richman
- Rx-Info Ltd, Exeter Science Park, 6 Babbage Way, Exeter, EX5 2FN, UK
| | - Dominick Shaw
- NIHR Respiratory Biomedical Research Centre, University of Nottingham, Nottingham, NG5 1PB, UK
| | - Emma Thomas-Jones
- Centre for Trials Research, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS, UK
| | - Robert M. West
- University of Leeds, Worsley Building, Clarendon Way, Leeds, LS2 9LU, UK
| | - Enitan D. Carrol
- Department of Clinical Infection, Microbiology and Immunology, University of Liverpool Institute of Infection, Veterinary and Ecological Sciences, Ronald Ross Building, 8 West Derby Street, Liverpool, L69 7BE, UK
| | - Philip Pallmann
- Centre for Trials Research, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS, UK
| | - Jonathan A. T. Sandoe
- Department of Microbiology, The Old Medical School, The General Infirmary at Leeds, Leeds, LS1 3EX, UK
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18
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Budgell EP, Davies TJ, Donker T, Hopkins S, Wyllie DH, Peto TEA, Gill MJ, Llewelyn MJ, Walker AS. Impact of hospital antibiotic use on patient-level risk of death among 36,124,372 acute and medical admissions in England. J Infect 2021; 84:311-320. [PMID: 34963640 DOI: 10.1016/j.jinf.2021.12.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 12/03/2021] [Accepted: 12/17/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Initiatives to curb hospital antibiotic use might be associated with harm from under-treatment. We examined the extent to which variation in hospital antibiotic prescribing is associated with mortality risk in acute/general medicine inpatients. METHODS This ecological analysis examined Hospital Episode Statistics from 36,124,372 acute/general medicine admissions (≥16y) to 135 acute hospitals in England, 01/April/2010-31/March/2017. Random-effects meta-regression was used to investigate whether heterogeneity in adjusted 30-day mortality was associated with hospital-level antibiotic use, measured in defined-daily-doses (DDD)/1,000 bed-days. Models also considered DDDs/1,000 admissions and DDDs for narrow-spectrum/broad-spectrum antibiotics, parenteral/oral, and local interpretations of World Health Organization Access, Watch, and Reserve antibiotics. RESULTS Hospital-level antibiotic DDDs/1,000 bed-days varied 15-fold with comparable variation in broad-spectrum, parenteral, and Reserve antibiotic use. After extensive adjusting for hospital case-mix, the probability of 30-day mortality changed -0.010% (95% CI: -0.064,+0.044) for each increase of 500 hospital-level antibiotic DDDs/1,000 bed-days. Analyses of other metrics of antibiotic use showed no consistent association with mortality risk. CONCLUSIONS We found no evidence that wide variation in hospital antibiotic use is associated with adjusted mortality risk in acute/general medicine inpatients. Using low-prescribing hospitals as benchmarks could help drive safe and substantial reductions in antibiotic consumption of up-to one-third in this population.
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Affiliation(s)
- Eric P Budgell
- Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Timothy J Davies
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Tjibbe Donker
- Institute for Infection Prevention and Hospital Epidemiology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Susan Hopkins
- National Infection Service, Public Health England, UK
| | | | - Tim E A Peto
- Nuffield Department of Medicine, University of Oxford, Oxford, UK; NIHR Biomedical Research Centre, Oxford, UK; National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Oxford, UK
| | - Martin J Gill
- Clinical Microbiology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Martin J Llewelyn
- Global Health and Infectious Diseases, Brighton and Sussex Medical School, University of Sussex, Brighton, UK; Department of Microbiology and Infection, Royal Sussex County Hospital, Brighton, UK
| | - A Sarah Walker
- Nuffield Department of Medicine, University of Oxford, Oxford, UK; NIHR Biomedical Research Centre, Oxford, UK; National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Oxford, UK
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19
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Munro APS, Janani L, Cornelius V, Aley PK, Babbage G, Baxter D, Bula M, Cathie K, Chatterjee K, Dodd K, Enever Y, Gokani K, Goodman AL, Green CA, Harndahl L, Haughney J, Hicks A, van der Klaauw AA, Kwok J, Lambe T, Libri V, Llewelyn MJ, McGregor AC, Minassian AM, Moore P, Mughal M, Mujadidi YF, Murira J, Osanlou O, Osanlou R, Owens DR, Pacurar M, Palfreeman A, Pan D, Rampling T, Regan K, Saich S, Salkeld J, Saralaya D, Sharma S, Sheridan R, Sturdy A, Thomson EC, Todd S, Twelves C, Read RC, Charlton S, Hallis B, Ramsay M, Andrews N, Nguyen-Van-Tam JS, Snape MD, Liu X, Faust SN. Safety and immunogenicity of seven COVID-19 vaccines as a third dose (booster) following two doses of ChAdOx1 nCov-19 or BNT162b2 in the UK (COV-BOOST): a blinded, multicentre, randomised, controlled, phase 2 trial. Lancet 2021; 398:2258-2276. [PMID: 34863358 PMCID: PMC8639161 DOI: 10.1016/s0140-6736(21)02717-3] [Citation(s) in RCA: 407] [Impact Index Per Article: 135.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 11/17/2021] [Accepted: 11/19/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND Few data exist on the comparative safety and immunogenicity of different COVID-19 vaccines given as a third (booster) dose. To generate data to optimise selection of booster vaccines, we investigated the reactogenicity and immunogenicity of seven different COVID-19 vaccines as a third dose after two doses of ChAdOx1 nCov-19 (Oxford-AstraZeneca; hereafter referred to as ChAd) or BNT162b2 (Pfizer-BioNtech, hearafter referred to as BNT). METHODS COV-BOOST is a multicentre, randomised, controlled, phase 2 trial of third dose booster vaccination against COVID-19. Participants were aged older than 30 years, and were at least 70 days post two doses of ChAd or at least 84 days post two doses of BNT primary COVID-19 immunisation course, with no history of laboratory-confirmed SARS-CoV-2 infection. 18 sites were split into three groups (A, B, and C). Within each site group (A, B, or C), participants were randomly assigned to an experimental vaccine or control. Group A received NVX-CoV2373 (Novavax; hereafter referred to as NVX), a half dose of NVX, ChAd, or quadrivalent meningococcal conjugate vaccine (MenACWY)control (1:1:1:1). Group B received BNT, VLA2001 (Valneva; hereafter referred to as VLA), a half dose of VLA, Ad26.COV2.S (Janssen; hereafter referred to as Ad26) or MenACWY (1:1:1:1:1). Group C received mRNA1273 (Moderna; hereafter referred to as m1273), CVnCov (CureVac; hereafter referred to as CVn), a half dose of BNT, or MenACWY (1:1:1:1). Participants and all investigatory staff were blinded to treatment allocation. Coprimary outcomes were safety and reactogenicity and immunogenicity of anti-spike IgG measured by ELISA. The primary analysis for immunogenicity was on a modified intention-to-treat basis; safety and reactogenicity were assessed in the intention-to-treat population. Secondary outcomes included assessment of viral neutralisation and cellular responses. This trial is registered with ISRCTN, number 73765130. FINDINGS Between June 1 and June 30, 2021, 3498 people were screened. 2878 participants met eligibility criteria and received COVID-19 vaccine or control. The median ages of ChAd/ChAd-primed participants were 53 years (IQR 44-61) in the younger age group and 76 years (73-78) in the older age group. In the BNT/BNT-primed participants, the median ages were 51 years (41-59) in the younger age group and 78 years (75-82) in the older age group. In the ChAd/ChAD-primed group, 676 (46·7%) participants were female and 1380 (95·4%) were White, and in the BNT/BNT-primed group 770 (53·6%) participants were female and 1321 (91·9%) were White. Three vaccines showed overall increased reactogenicity: m1273 after ChAd/ChAd or BNT/BNT; and ChAd and Ad26 after BNT/BNT. For ChAd/ChAd-primed individuals, spike IgG geometric mean ratios (GMRs) between study vaccines and controls ranged from 1·8 (99% CI 1·5-2·3) in the half VLA group to 32·3 (24·8-42·0) in the m1273 group. GMRs for wild-type cellular responses compared with controls ranged from 1·1 (95% CI 0·7-1·6) for ChAd to 3·6 (2·4-5·5) for m1273. For BNT/BNT-primed individuals, spike IgG GMRs ranged from 1·3 (99% CI 1·0-1·5) in the half VLA group to 11·5 (9·4-14·1) in the m1273 group. GMRs for wild-type cellular responses compared with controls ranged from 1·0 (95% CI 0·7-1·6) for half VLA to 4·7 (3·1-7·1) for m1273. The results were similar between those aged 30-69 years and those aged 70 years and older. Fatigue and pain were the most common solicited local and systemic adverse events, experienced more in people aged 30-69 years than those aged 70 years or older. Serious adverse events were uncommon, similar in active vaccine and control groups. In total, there were 24 serious adverse events: five in the control group (two in control group A, three in control group B, and zero in control group C), two in Ad26, five in VLA, one in VLA-half, one in BNT, two in BNT-half, two in ChAd, one in CVn, two in NVX, two in NVX-half, and one in m1273. INTERPRETATION All study vaccines boosted antibody and neutralising responses after ChAd/ChAd initial course and all except one after BNT/BNT, with no safety concerns. Substantial differences in humoral and cellular responses, and vaccine availability will influence policy choices for booster vaccination. FUNDING UK Vaccine Taskforce and National Institute for Health Research.
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Affiliation(s)
- Alasdair P S Munro
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Leila Janani
- Imperial Clinical Trials Unit, Imperial College London, London, UK
| | | | - Parvinder K Aley
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Gavin Babbage
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Marcin Bula
- NIHR Liverpool and Broadgreen Clinical Research Facility, Liverpool, UK
| | - Katrina Cathie
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Krishna Chatterjee
- NIHR Cambridge Clinical Research Facility, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Kate Dodd
- NIHR Liverpool and Broadgreen Clinical Research Facility, Liverpool, UK
| | | | - Karishma Gokani
- NIHR/Wellcome Clinical Research Facility, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Anna L Goodman
- Department of Infection, Guy's and St Thomas' NHS Foundation Trust, London, UK; MRC Clinical Trials Unit, University College London, London, UK
| | - Christopher A Green
- NIHR/Wellcome Clinical Research Facility, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Linda Harndahl
- Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - John Haughney
- Queen Elizabeth University Hospital, NHS Greater Glasgow & Clyde, Glasgow, UK
| | | | - Agatha A van der Klaauw
- Wellcome-MRC Institute of Metabolic Science, Department of Clinical Biochemistry, University of Cambridge, Cambridge, UK
| | - Jonathan Kwok
- Cancer Research UK Oxford Centre, University of Oxford, Oxford, UK
| | - Teresa Lambe
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Vincenzo Libri
- NIHR UCLH Clinical Research Facility and NIHR UCLH Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Alastair C McGregor
- Department of Infectious Diseases and Tropical Medicine, London Northwest University Healthcare, London, UK
| | - Angela M Minassian
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; Jenner Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | | | - Yama F Mujadidi
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Jennifer Murira
- NIHR Leeds Clinical Research Facility, Leeds Teaching Hospitals Trust and University of Leeds, Leeds, UK
| | - Orod Osanlou
- North Wales Clinical Research Facility, Betsi Cadwaladr University Health Board and Bangor University, Bangor, UK
| | - Rostam Osanlou
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Daniel R Owens
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Mihaela Pacurar
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Adrian Palfreeman
- University Hospitals of Leicester NHS Trust, University of Leicester, Leicester, UK
| | - Daniel Pan
- University Hospitals of Leicester NHS Trust, University of Leicester, Leicester, UK
| | - Tommy Rampling
- NIHR UCLH Clinical Research Facility and NIHR UCLH Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK
| | - Karen Regan
- Bradford Institute for Health Research and Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Stephen Saich
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Jo Salkeld
- Department of Infection, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Dinesh Saralaya
- Bradford Institute for Health Research and Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Sunil Sharma
- University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Ray Sheridan
- Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, UK
| | - Ann Sturdy
- Department of Infectious Diseases and Tropical Medicine, London Northwest University Healthcare, London, UK
| | - Emma C Thomson
- Queen Elizabeth University Hospital, NHS Greater Glasgow & Clyde, Glasgow, UK; MRC University of Glasgow Centre for Virus Research, Glasgow, UK
| | - Shirley Todd
- Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, UK
| | - Chris Twelves
- NIHR Leeds Clinical Research Facility, Leeds Teaching Hospitals Trust and University of Leeds, Leeds, UK
| | - Robert C Read
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | | | | | - Mary Ramsay
- UK Health Security Agency, Colindale, London, UK
| | - Nick Andrews
- UK Health Security Agency, Colindale, London, UK
| | - Jonathan S Nguyen-Van-Tam
- Division of Epidemiology and Public Health, University of Nottingham School of Medicine, Nottingham, UK
| | - Matthew D Snape
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Xinxue Liu
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Saul N Faust
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK.
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Ratnaraja NV, Davies AP, Atkins BL, Dhillon R, Mahida N, Moses S, Herman J, Checkley A, Partridge D, Llewelyn MJ. Best practice standards for the delivery of NHS infection services in the United Kingdom. Clinical Infection in Practice 2021; 12:100095. [PMID: 36338177 PMCID: PMC9623038 DOI: 10.1016/j.clinpr.2021.100095] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 08/17/2021] [Accepted: 08/24/2021] [Indexed: 11/18/2022] Open
Abstract
Infection expertise in the NHS has historically been provided predominantly by hospital-based medical microbiologists responsible for provision of diagnostic services and advice to front-line clinicians. While most hospitals had consultant-led microbiology departments, infectious iiseases departments were based in a small number of specialist centres. The demand for infection expertise is growing in the NHS, driven by advances in medical care, increasing awareness of the impact of antibiotic resistant and healthcare associated infections and threats from emerging infectious diseases. At the same time diagnostic services are being reorganised into pathology networks. The Combined Infection Training (CIT) is delivering a consultant workforce with expertise both in laboratory diagnostic practice and delivery of direct patient care. These changes create challenges for delivery of high quality infection expertise equitably across the NHS. They also offer an opportunity to shape infection services to meet clinical and laboratory demands. To date there has not been an attempt to bring together a single set of best practice guidelines for the requirements of an infection service. This document sets out seven standards. These are written to be practical and flexible according to the diverse ways in which infection expertise may be required across the NHS. It has been prepared by the Clinical Services Committee of the British Infection Association drawing on published evidence and guidance where they exist and on the group’s extensive experience of delivering infection services in hospitals across the NHS. It was then refined with input from the RCP Joint Specialist committee (JSC) and the RCPath Specialist Advisory Committee (SAC) and through consultation with the RCPath membership. It has been endorsed by the Royal College of Pathologists and the Royal College of Physicians. It will be reviewed annually by the CSC and updated as additional evidence becomes available.
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Young BC, Wu CH, Charlesworth J, Earle S, Price JR, Gordon NC, Cole K, Dunn L, Liu E, Oakley S, Godwin H, Fung R, Miller R, Knox K, Votintseva A, Quan TP, Tilley R, Scarborough M, Crook DW, Peto TE, Walker AS, Llewelyn MJ, Wilson DJ. Antimicrobial resistance determinants are associated with Staphylococcus aureus bacteraemia and adaptation to the healthcare environment: a bacterial genome-wide association study. Microb Genom 2021; 7:000700. [PMID: 34812717 PMCID: PMC8743558 DOI: 10.1099/mgen.0.000700] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 09/30/2021] [Indexed: 12/30/2022] Open
Abstract
Staphylococcus aureus is a major bacterial pathogen in humans, and a dominant cause of severe bloodstream infections. Globally, antimicrobial resistance (AMR) in S. aureus remains challenging. While human risk factors for infection have been defined, contradictory evidence exists for the role of bacterial genomic variation in S. aureus disease. To investigate the contribution of bacterial lineage and genomic variation to the development of bloodstream infection, we undertook a genome-wide association study comparing bacteria from 1017 individuals with bacteraemia to 984 adults with asymptomatic S. aureus nasal carriage. Within 984 carriage isolates, we also compared healthcare-associated (HA) carriage with community-associated (CA) carriage. All major global lineages were represented in both bacteraemia and carriage, with no evidence for different infection rates. However, kmers tagging trimethoprim resistance-conferring mutation F99Y in dfrB were significantly associated with bacteraemia-vs-carriage (P=10-8.9-10-9.3). Pooling variation within genes, bacteraemia-vs-carriage was associated with the presence of mecA (HMP=10-5.3) as well as the presence of SCCmec (HMP=10-4.4). Among S. aureus carriers, no lineages were associated with HA-vs-CA carriage. However, we found a novel signal of HA-vs-CA carriage in the foldase protein prsA, where kmers representing conserved sequence allele were associated with CA carriage (P=10-7.1-10-19.4), while in gyrA, a ciprofloxacin resistance-conferring mutation, L84S, was associated with HA carriage (P=10-7.2). In an extensive study of S. aureus bacteraemia and nasal carriage in the UK, we found strong evidence that all S. aureus lineages are equally capable of causing bloodstream infection, and of being carried in the healthcare environment. Genomic variation in the foldase protein prsA is a novel genomic marker of healthcare origin in S. aureus but was not associated with bacteraemia. AMR determinants were associated with both bacteraemia and healthcare-associated carriage, suggesting that AMR increases the propensity not only to survive in healthcare environments, but also to cause invasive disease.
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Affiliation(s)
- Bernadette C. Young
- Nuffield Department of Medicine, Experimental Medicine Division, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
- Microbiology and Infectious Diseases Department, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Chieh-Hsi Wu
- Nuffield Department of Medicine, Experimental Medicine Division, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Jane Charlesworth
- Nuffield Department of Medicine, Experimental Medicine Division, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Sarah Earle
- Big Data Institute, Nuffield Department of Population Health, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Old Road Campus, Oxford, OX3 7LF, UK
| | - James R. Price
- Department of Infectious Diseases and Microbiology, Royal Sussex County Hospital, Brighton BN2 5BE, UK
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Falmer BN1 9PS, UK
| | - N. Claire Gordon
- Nuffield Department of Medicine, Experimental Medicine Division, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
- Microbiology and Infectious Diseases Department, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Kevin Cole
- Department of Infectious Diseases and Microbiology, Royal Sussex County Hospital, Brighton BN2 5BE, UK
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Falmer BN1 9PS, UK
| | - Laura Dunn
- Microbiology and Infectious Diseases Department, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Elian Liu
- Microbiology and Infectious Diseases Department, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Sarah Oakley
- Microbiology and Infectious Diseases Department, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Heather Godwin
- Nuffield Department of Medicine, Experimental Medicine Division, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Rowena Fung
- Nuffield Department of Medicine, Experimental Medicine Division, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Ruth Miller
- Nuffield Department of Medicine, Experimental Medicine Division, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Kyle Knox
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Antonina Votintseva
- Nuffield Department of Medicine, Experimental Medicine Division, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - T. Phuong Quan
- Nuffield Department of Medicine, Experimental Medicine Division, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
- National Institute for Health Research, Oxford Biomedical Research Centre, Oxford, UK
- NIHR Health Protection Unit in Healthcare Associated Infections and Antimicrobial Resistance at University of Oxford in partnership with Public Health England, Oxford, UK
| | - Robert Tilley
- Department of Microbiology, University Hospitals Plymouth NHS Trust, Derriford Hospital, Plymouth PL6 8DH, UK
| | - Matthew Scarborough
- Microbiology and Infectious Diseases Department, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Derrick W. Crook
- Nuffield Department of Medicine, Experimental Medicine Division, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
- Microbiology and Infectious Diseases Department, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, UK
- National Institute for Health Research, Oxford Biomedical Research Centre, Oxford, UK
- NIHR Health Protection Unit in Healthcare Associated Infections and Antimicrobial Resistance at University of Oxford in partnership with Public Health England, Oxford, UK
| | - Timothy E. Peto
- Nuffield Department of Medicine, Experimental Medicine Division, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
- Microbiology and Infectious Diseases Department, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, UK
- National Institute for Health Research, Oxford Biomedical Research Centre, Oxford, UK
- NIHR Health Protection Unit in Healthcare Associated Infections and Antimicrobial Resistance at University of Oxford in partnership with Public Health England, Oxford, UK
| | - A. Sarah Walker
- Nuffield Department of Medicine, Experimental Medicine Division, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
- National Institute for Health Research, Oxford Biomedical Research Centre, Oxford, UK
- NIHR Health Protection Unit in Healthcare Associated Infections and Antimicrobial Resistance at University of Oxford in partnership with Public Health England, Oxford, UK
| | - Martin J. Llewelyn
- Department of Infectious Diseases and Microbiology, Royal Sussex County Hospital, Brighton BN2 5BE, UK
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Falmer BN1 9PS, UK
| | - Daniel J. Wilson
- Big Data Institute, Nuffield Department of Population Health, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Old Road Campus, Oxford, OX3 7LF, UK
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Wilson J, Carson G, Fitzgerald S, Llewelyn MJ, Jenkins D, Parker S, Boies A, Thomas J, Sutcliffe K, Sowden AJ, O'Mara-Eves A, Stansfield C, Harriss E, Reilly J. Are medical procedures that induce coughing or involve respiratory suctioning associated with increased generation of aerosols and risk of SARS-CoV-2 infection? A rapid systematic review. J Hosp Infect 2021; 116:37-46. [PMID: 34245806 PMCID: PMC8264274 DOI: 10.1016/j.jhin.2021.06.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/28/2021] [Accepted: 06/30/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND The risk of transmission of SARS-CoV-2 from aerosols generated by medical procedures is a cause for concern. AIM To evaluate the evidence for aerosol production and transmission of respiratory infection associated with procedures that involve airway suctioning or induce coughing/sneezing. METHODS The review was informed by PRISMA guidelines. Searches were conducted in PubMed for studies published between January 1st, 2003 and October 6th, 2020. Included studies examined whether nasogastric tube insertion, lung function tests, nasendoscopy, dysphagia assessment, or suctioning for airway clearance result in aerosol generation or transmission of SARS-CoV-2, SARS-CoV, MERS, or influenza. Risk of bias assessment focused on robustness of measurement, control for confounding, and applicability to clinical practice. FINDINGS Eighteen primary studies and two systematic reviews were included. Three epidemiological studies found no association between nasogastric tube insertion and acquisition of respiratory infections. One simulation study found low/very low production of aerosols associated with pulmonary lung function tests. Seven simulation studies of endoscopic sinus surgery suggested significant increases in aerosols but findings were inconsistent; two clinical studies found airborne particles associated with the use of microdebriders/drills. Some simulation studies did not use robust measures to detect particles and are difficult to equate to clinical conditions. CONCLUSION There was an absence of evidence to suggest that the procedures included in the review were associated with an increased risk of transmission of respiratory infection. In order to better target precautions to mitigate risk, more research is required to determine the characteristics of medical procedures and patients that increase the risk of transmission of SARS-CoV-2.
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Affiliation(s)
- J Wilson
- Richard Wells Research Centre, University of West London, London, UK.
| | - G Carson
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - S Fitzgerald
- Department of Engineering, University of Cambridge, Cambridge, UK
| | - M J Llewelyn
- Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - D Jenkins
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - S Parker
- Defence Science and Technology Laboratory, Porton Down, Salisbury, UK
| | - A Boies
- Department of Engineering, University of Cambridge, Cambridge, UK
| | - J Thomas
- EPPI-Centre, Social Research Institute, UCL Institute of Education, University College London, London, UK
| | - K Sutcliffe
- EPPI-Centre, Social Research Institute, UCL Institute of Education, University College London, London, UK
| | - A J Sowden
- Centre for Reviews and Dissemination, University of York, York, UK
| | - A O'Mara-Eves
- EPPI-Centre, Social Research Institute, UCL Institute of Education, University College London, London, UK
| | - C Stansfield
- EPPI-Centre, Social Research Institute, UCL Institute of Education, University College London, London, UK
| | - E Harriss
- Bodleian Health Care Libraries, John Radcliffe Hospital, Oxford, UK
| | - J Reilly
- Research Centre for Health (ReaCH), Glasgow Caledonian University, Glasgow, UK
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Price JR, Yokoyama M, Cole K, Sweetman J, Behar L, Stoneham S, Cantillon D, Waddell SJ, Hyde J, Alam R, Crook D, Paul J, Llewelyn MJ. Undetected carriage explains apparent Staphylococcus aureus acquisition in a non-outbreak healthcare setting. J Infect 2021; 83:332-338. [PMID: 34303737 DOI: 10.1016/j.jinf.2021.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 07/18/2021] [Accepted: 07/19/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Previous studies have been unable to identify patient or staff reservoirs for the majority of the nosocomial S. aureus acquisitions which occur in the presence of good infection control practice. We set out to establish the extent to which undetected pre-existing carriage explains apparent nosocomial S. aureus acquisition. METHODS Over two years elective cardiothoracic admissions were screened for S. aureus carriage before and during hospital admission. Routine screening (nose/groin/wound sampling), was supplemented by sampling additional body sites (axilla/throat/rectum) and culture-based methods optimised to detect fastidious phenotypes (small colony variants, cell wall deficient variants) and molecular identification by PCR. RESULTS 35% of participants (53/151) were S. aureus carriers according to routine pre-healthcare screening; increasing to 42% (63/151) when additional body sites and enhanced cultures were employed. 71% (5/7) of apparent acquisitions were explained by pre-existing carriage using augmented measures. Enhanced culture identified a minority of colonised individuals (3/151 including 1 MRSA carrier) who were undetected by routine and additional screening cultures. 4/14 (29%) participants who became culture-negative during admission had S. aureus genomic material detected at discharge. CONCLUSIONS Conventional sampling under-estimates carriage of S. aureus and this explains the majority of apparent S. aureus acquisitions among elective cardiothoracic patients.
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Affiliation(s)
- James R Price
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Falmer, Brighton, BN1 9PS, United Kingdom.
| | - Maho Yokoyama
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Falmer, Brighton, BN1 9PS, United Kingdom.
| | - Kevin Cole
- Public Health England, Royal Sussex County Hospital, Brighton, BN2 5BE, United Kingdom.
| | - Jonathan Sweetman
- Clinical Investigation Research Unit, Brighton and Sussex University Hospital NHS Trust, Brighton, BN2 5BE, United Kingdom.
| | - Laura Behar
- Clinical Investigation Research Unit, Brighton and Sussex University Hospital NHS Trust, Brighton, BN2 5BE, United Kingdom.
| | - Simon Stoneham
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Falmer, Brighton, BN1 9PS, United Kingdom.
| | - Daire Cantillon
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Falmer, Brighton, BN1 9PS, United Kingdom.
| | - Simon J Waddell
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Falmer, Brighton, BN1 9PS, United Kingdom.
| | - Jonathan Hyde
- Clinical Investigation Research Unit, Brighton and Sussex University Hospital NHS Trust, Brighton, BN2 5BE, United Kingdom.
| | - Ruhina Alam
- Clinical Investigation Research Unit, Brighton and Sussex University Hospital NHS Trust, Brighton, BN2 5BE, United Kingdom.
| | - Derrick Crook
- Department of Experimental Medicine, John Radcliffe Hospital, Oxford, OX3 9DU, United Kingdom.
| | - John Paul
- Public Health England, Royal Sussex County Hospital, Brighton, BN2 5BE, United Kingdom.
| | - Martin J Llewelyn
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Falmer, Brighton, BN1 9PS, United Kingdom.
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Prazak J, Irincheeva I, Llewelyn MJ, Stolz D, García de Guadiana Romualdo L, Graf R, Reding T, Klein HJ, Eggimann P, Que YA. Accuracy of pancreatic stone protein for the diagnosis of infection in hospitalized adults: a systematic review and individual patient level meta-analysis. Crit Care 2021; 25:182. [PMID: 34049579 PMCID: PMC8164316 DOI: 10.1186/s13054-021-03609-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 05/19/2021] [Indexed: 12/21/2022]
Abstract
Background Accurate biomarkers to diagnose infection are lacking. Studies reported good performance of pancreatic stone protein (PSP) to detect infection. The objective of the study was to determine the performance of PSP in diagnosing infection across hospitalized patients and calculate a threshold value for that purpose. Methods A systematic search across Cochrane Central Register of Controlled Trials and MEDLINE databases (1966–March 2019) for studies on PSP published in English using ‘pancreatic stone protein’, ‘PSP’, ‘regenerative protein’, ‘lithostatin’ combined with ‘infection’ and ‘sepsis’ found 44 records. The search was restricted to the five trials that evaluated PSP for the initial detection of infection in hospitalized adults. Individual patient data were obtained from the investigators of all eligible trials. Data quality and validity was assessed according to PRISMA guidelines. We choose a fixed-effect model to calculate the PSP cut-off value that best discriminates infected from non-infected patients. Results Infection was confirmed in 371 of 631 patients. The median (IQR) PSP value of infected versus uninfected patients was 81.5 (30.0–237.5) versus 19.2 (12.6–33.57) ng/ml, compared to 150 (82.70–229.55) versus 58.25 (15.85–120) mg/l for C-reactive protein (CRP) and 0.9 (0.29–4.4) versus 0.15 (0.08–0.5) ng/ml for procalcitonin (PCT). Using a PSP cut-off of 44.18 ng/ml, the ROC AUC to detect infection was 0.81 (0.78–0.85) with a sensitivity of 0.66 (0.61–0.71), specificity of 0.83 (0.78–0.88), PPV of 0.85 (0.81–0.89) and NPV of 0.63 (0.58–0.68). When a model combining PSP and CRP was used, the ROC AUC improved to 0.90 (0.87–0.92) with higher sensitivity 0.81 (0.77–0.85) and specificity 0.84 (0.79–0.90) for discriminating infection from non-infection. Adding PCT did not improve the performance further. Conclusions PSP is a promising biomarker to diagnose infections in hospitalized patients. Using a cut-off value of 44.18 ng/ml, PSP performs better than CRP or PCT across the considered studies. The combination of PSP with CRP further enhances its accuracy. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03609-2.
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Affiliation(s)
- Josef Prazak
- Department of Intensive Care Medicine, INO E-403, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | | | | | - Daiana Stolz
- Clinic of Pulmonary Medicine and Respiratory Cell Research, University Hospital Basel, Basel, Switzerland
| | | | - Rolf Graf
- Department of Visceral and Transplantation Surgery, Universitätsspital Zürich, Zurich, Switzerland
| | - Theresia Reding
- Department of Visceral and Transplantation Surgery, Universitätsspital Zürich, Zurich, Switzerland
| | - Holger J Klein
- Department of Plastic Surgery and Hand Surgery, Burn Center Zurich, Universitässpital Zürich, Zurich, Switzerland
| | - Philippe Eggimann
- Department of Locomotor Apparatus, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Yok-Ai Que
- Department of Intensive Care Medicine, INO E-403, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland.
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Coburn J, Bone F, Hopkins MM, Stirling A, Mestre-Ferrandiz J, Arapostathis S, Llewelyn MJ. Appraising research policy instrument mixes: a multicriteria mapping study in six European countries of diagnostic innovation to manage antimicrobial resistance. Res Policy 2021; 50:104140. [PMID: 33941992 PMCID: PMC8039188 DOI: 10.1016/j.respol.2020.104140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
The following contributions are provided: A general process for conducting systematic prospective appraisal of policy options within the field of research policy, using multicriteria mapping (MCM). Novel methods for systematically analysing MCM data using pairwise comparison and merit orders which improve the utility of the MCM method. Quantitative findings (derived using MCM) on the appraisal of policy options for antimicrobial resistance (AMR) by 47 experts from six European countries, providing seven stakeholder perspectives, and identifying most and least favoured policy options. Qualitative findings (derived using MCM) addressing different modes of reasoning as to why contrasting policy options may be expected to perform well or poorly in different settings and from different perspectives. Qualitative findings (derived using MCM) underpinning a framework for policy design that may be useful for research policy around AMR. Quantitative findings (derived not using MCM) concerning those particular options that interviewees identified as most complementary to each other, supported by qualitative illustrations and qualifications.
This article provides prospective appraisal of key policy instruments intended to stimulate innovation to combat antimicrobial resistance (AMR). AMR refers to the ability of microbes to evolve resistance to those treatments designed to kill them, and is associated with the overuse or misuse of medicines such as antibiotics. AMR is an emerging global challenge with major implications for healthcare and society as a whole. Diagnostic tests for infectious diseases can guide decision making when prescribing medicines, so reducing inappropriate drug use. In the context of growing international interest in policies to stimulate innovation in AMR diagnostics, this study uses multicriteria mapping (MCM) to appraise a range of policy instruments in order to understand their potential performance while also highlighting the uncertainties that stakeholders hold about such interventions in complex contexts. A contribution of the article is the demonstration of a novel method to analyse and visualise MCM data in order to reveal stakeholder inclinations towards particular options while exploring interviewees’ uncertainties about the effectiveness of each instrument's design or implementation. The article reports results from six European countries (Germany, Greece, Italy, the Netherlands, Spain and the UK). The findings reveal which policy instruments are deemed most likely to perform well, and why, across stakeholder groups and national settings, with areas of common ground and difference being identified. Importantly, the conclusions presented here differ from prominent policy discourse, with international implications for the design of mixes of policy instruments to combat AMR. Strategic and practical methodological implications also emerge for general appraisal of innovation policy instrument mixes.
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Affiliation(s)
- Josie Coburn
- Science Policy Research Unit, University of Sussex Business School, University of Sussex, Falmer, Brighton, United Kingdom
| | - Frederique Bone
- Science Policy Research Unit, University of Sussex Business School, University of Sussex, Falmer, Brighton, United Kingdom
| | - Michael M Hopkins
- Science Policy Research Unit, University of Sussex Business School, University of Sussex, Falmer, Brighton, United Kingdom
| | - Andy Stirling
- Science Policy Research Unit, University of Sussex Business School, University of Sussex, Falmer, Brighton, United Kingdom
| | | | - Stathis Arapostathis
- Department of History and Philosophy of Science, National and Kapodistrian University of Athens, Athens, Greece
| | - Martin J Llewelyn
- Brighton and Sussex Medical School, Falmer, Brighton, United Kingdom
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Powell N, Howard P, Llewelyn MJ, Szakmany T, Albur M, Bond SE, Euden J, Brookes-Howell L, Dark P, Hellyer TP, Hopkins S, McCullagh IJ, Ogden M, Pallmann P, Parsons H, Partridge DG, Shaw DE, Shinkins B, Todd S, Thomas-Jones E, West R, Carrol ED, Sandoe JAT. Use of Procalcitonin during the First Wave of COVID-19 in the Acute NHS Hospitals: A Retrospective Observational Study. Antibiotics (Basel) 2021; 10:516. [PMID: 34062898 PMCID: PMC8147337 DOI: 10.3390/antibiotics10050516] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 04/26/2021] [Accepted: 04/29/2021] [Indexed: 01/08/2023] Open
Abstract
A minority of patients presenting to hospital with COVID-19 have bacterial co-infection. Procalcitonin testing may help identify patients for whom antibiotics should be prescribed or withheld. This study describes the use of procalcitonin in English and Welsh hospitals during the first wave of the COVID-19 pandemic. A web-based survey of antimicrobial leads gathered data about the use of procalcitonin testing. Responses were received from 148/151 (98%) eligible hospitals. During the first wave of the COVID-19 pandemic, there was widespread introduction and expansion of PCT use in NHS hospitals. The number of hospitals using PCT in emergency/acute admissions rose from 17 (11%) to 74/146 (50.7%) and use in Intensive Care Units (ICU) increased from 70 (47.6%) to 124/147 (84.4%). This increase happened predominantly in March and April 2020, preceding NICE guidance. Approximately half of hospitals used PCT as a single test to guide decisions to discontinue antibiotics and half used repeated measurements. There was marked variation in the thresholds used for empiric antibiotic cessation and guidance about interpretation of values. Procalcitonin testing has been widely adopted in the NHS during the COVID-19 pandemic in an unevidenced, heterogeneous way and in conflict with relevant NICE guidance. Further research is needed urgently that assesses the impact of this change on antibiotic prescribing and patient safety.
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Affiliation(s)
- Neil Powell
- Pharmacy Department, Royal Cornwall Hospital Trust, Truro TR1 3LJ, UK
| | - Philip Howard
- School of Healthcare, Faculty of Medicine and Health, University of Leeds, Leeds LS2 9JT, UK;
- Department of Medicines Management and Pharmacy, Leeds Teaching Hospitals, Leeds General Infirmary, Leeds LS1 3EX, UK
| | - Martin J. Llewelyn
- Brighton and Sussex Medical School, University of Sussex, Brighton BN1 9PS, UK;
| | - Tamas Szakmany
- Grange University Hospital, Aneurin Bevan University Health Board, Llanyravon, Cwmbran NP44 2XJ, UK;
- Department of Anaesthesia, Intensive Care and Pain Medicine, Division of Population Medicine, Cardiff University, Cardiff CF14 4XN, UK
| | | | - Stuart E Bond
- Mid Yorkshire Hospitals NHS Trust, Wakefield WF1 4DG, UK;
- School of Applied Sciences, University of Huddersfield, Huddersfield HD13DH, UK
| | - Joanne Euden
- Centre for Trials Research, Neuadd Meirionydd, Cardiff University, Heath Park, Cardiff CF14 4YS, UK; (J.E.); (L.B.-H.); (P.P.); (E.T.-J.)
| | - Lucy Brookes-Howell
- Centre for Trials Research, Neuadd Meirionydd, Cardiff University, Heath Park, Cardiff CF14 4YS, UK; (J.E.); (L.B.-H.); (P.P.); (E.T.-J.)
| | - Paul Dark
- Manchester NIHR Biomedical Research Centre, University of Manchester, Manchester M13 9PL, UK;
| | - Thomas P Hellyer
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne NE1 7RU, UK;
| | | | - Iain J McCullagh
- The Newcastle upon Tyne hospitals NHS Foundation Trust, Newcastle Upon Tyne NE7 7DN, UK;
| | - Margaret Ogden
- Patient and Public Involvement Representative, NIHR, London SW1A 2NS, UK;
| | - Philip Pallmann
- Centre for Trials Research, Neuadd Meirionydd, Cardiff University, Heath Park, Cardiff CF14 4YS, UK; (J.E.); (L.B.-H.); (P.P.); (E.T.-J.)
| | - Helena Parsons
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK; (H.P.); (D.GP.)
| | - David G Partridge
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK; (H.P.); (D.GP.)
| | - Dominick E. Shaw
- Division of Respiratory Medicine, University of Nottingham, Nottingham NG7 2RD, UK;
| | - Bethany Shinkins
- Test Evaluation Group, Leeds Institute of Health Sciences, University of Leeds, Leeds LS2 9JT, UK;
| | - Stacy Todd
- Liverpool University Hospital NHS Foundation Trust, Liverpool L9 7AL, UK;
| | - Emma Thomas-Jones
- Centre for Trials Research, Neuadd Meirionydd, Cardiff University, Heath Park, Cardiff CF14 4YS, UK; (J.E.); (L.B.-H.); (P.P.); (E.T.-J.)
| | - Robert West
- Leeds Institute of Health Sciences, University of Leeds, Leeds LS2 9TJ, UK;
| | - Enitan D Carrol
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary & Ecological Sciences, University of Liverpool, Liverpool L69 3BX, UK;
| | - Jonathan A. T. Sandoe
- Healthcare Associated Infection Group, Leeds Institute of Medical Research, School of Medicine, University of Leeds, LS2 9JT, UK;
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Baskaran V, Lawrence H, Lansbury LE, Webb K, Safavi S, Zainuddin NI, Huq T, Eggleston C, Ellis J, Thakker C, Charles B, Boyd S, Williams T, Phillips C, Redmore E, Platt S, Hamilton E, Barr A, Venyo L, Wilson P, Bewick T, Daniel P, Dark P, Jeans AR, McCanny J, Edgeworth JD, Llewelyn MJ, Schmid ML, McKeever TM, Beed M, Lim WS. Co-infection in critically ill patients with COVID-19: an observational cohort study from England. J Med Microbiol 2021; 70:001350. [PMID: 33861190 PMCID: PMC8289210 DOI: 10.1099/jmm.0.001350] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 03/12/2021] [Indexed: 12/22/2022] Open
Abstract
Introduction. During previous viral pandemics, reported co-infection rates and implicated pathogens have varied. In the 1918 influenza pandemic, a large proportion of severe illness and death was complicated by bacterial co-infection, predominantly Streptococcus pneumoniae and Staphylococcus aureus.Gap statement. A better understanding of the incidence of co-infection in patients with COVID-19 infection and the pathogens involved is necessary for effective antimicrobial stewardship.Aim. To describe the incidence and nature of co-infection in critically ill adults with COVID-19 infection in England.Methodology. A retrospective cohort study of adults with COVID-19 admitted to seven intensive care units (ICUs) in England up to 18 May 2020, was performed. Patients with completed ICU stays were included. The proportion and type of organisms were determined at <48 and >48 h following hospital admission, corresponding to community and hospital-acquired co-infections.Results. Of 254 patients studied (median age 59 years (IQR 49-69); 64.6 % male), 139 clinically significant organisms were identified from 83 (32.7 %) patients. Bacterial co-infections/ co-colonisation were identified within 48 h of admission in 14 (5.5 %) patients; the commonest pathogens were Staphylococcus aureus (four patients) and Streptococcus pneumoniae (two patients). The proportion of pathogens detected increased with duration of ICU stay, consisting largely of Gram-negative bacteria, particularly Klebsiella pneumoniae and Escherichia coli. The co-infection/ co-colonisation rate >48 h after admission was 27/1000 person-days (95 % CI 21.3-34.1). Patients with co-infections/ co-colonisation were more likely to die in ICU (crude OR 1.78,95 % CI 1.03-3.08, P=0.04) compared to those without co-infections/ co-colonisation.Conclusion. We found limited evidence for community-acquired bacterial co-infection in hospitalised adults with COVID-19, but a high rate of Gram-negative infection acquired during ICU stay.
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Affiliation(s)
- Vadsala Baskaran
- Department of Respiratory Medicine, Nottingham University Hospital NHS Trust, Nottingham NG5 1PB, UK
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Clinical Sciences Building, Nottingham City Hospital Campus, Hucknall Road, Nottingham NG5 1PB, UK
- NIHR Nottingham Biomedical Research Centre, Queen’s Medical Centre, Nottingham NG7 2UH, UK
| | - Hannah Lawrence
- Department of Respiratory Medicine, Nottingham University Hospital NHS Trust, Nottingham NG5 1PB, UK
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Clinical Sciences Building, Nottingham City Hospital Campus, Hucknall Road, Nottingham NG5 1PB, UK
- NIHR Nottingham Biomedical Research Centre, Queen’s Medical Centre, Nottingham NG7 2UH, UK
| | - Louise E. Lansbury
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Clinical Sciences Building, Nottingham City Hospital Campus, Hucknall Road, Nottingham NG5 1PB, UK
| | - Karmel Webb
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Clinical Sciences Building, Nottingham City Hospital Campus, Hucknall Road, Nottingham NG5 1PB, UK
| | - Shahideh Safavi
- NIHR Nottingham Biomedical Research Centre, Queen’s Medical Centre, Nottingham NG7 2UH, UK
- Division of Respiratory Medicine, School of Medicine, University of Nottingham, Queens Medical Centre, Derby Rd, Nottingham NG7 2UH, UK
| | - Nurul I. Zainuddin
- Department of Respiratory Medicine, Nottingham University Hospital NHS Trust, Nottingham NG5 1PB, UK
| | - Tausif Huq
- Department of Respiratory Medicine, Nottingham University Hospital NHS Trust, Nottingham NG5 1PB, UK
| | - Charlotte Eggleston
- Department of Respiratory Medicine, Nottingham University Hospital NHS Trust, Nottingham NG5 1PB, UK
| | - Jayne Ellis
- University College London Hospitals NHS Foundation Trust, 250 Euston Rd, London NW1 2PG, UK
| | - Clare Thakker
- University College London Hospitals NHS Foundation Trust, 250 Euston Rd, London NW1 2PG, UK
| | - Bethan Charles
- Salford Royal NHS Foundation Trust, Stott Ln, Salford M6 8HD, UK
| | - Sara Boyd
- Guy’s and St Thomas’ NHS Foundation Trust, Great Maze Pond, London SE1 9RT, UK
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, L69 3GE, UK
| | - Tom Williams
- Guy’s and St Thomas’ NHS Foundation Trust, Great Maze Pond, London SE1 9RT, UK
| | - Claire Phillips
- Brighton and Sussex University Hospitals NHS trust, Eastern Road, Brighton BN2 1ES, UK
| | - Ethan Redmore
- Brighton and Sussex University Hospitals NHS trust, Eastern Road, Brighton BN2 1ES, UK
| | - Sarah Platt
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Freeman Rd, High Heaton, Newcastle upon Tyne NE7 7DN, UK
| | - Eve Hamilton
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Freeman Rd, High Heaton, Newcastle upon Tyne NE7 7DN, UK
| | - Andrew Barr
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Freeman Rd, High Heaton, Newcastle upon Tyne NE7 7DN, UK
| | - Lucy Venyo
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Freeman Rd, High Heaton, Newcastle upon Tyne NE7 7DN, UK
| | - Peter Wilson
- University College London Hospitals NHS Foundation Trust, 250 Euston Rd, London NW1 2PG, UK
| | - Tom Bewick
- University Hospitals of Derby and Burton NHS Foundation Trust, Uttoxeter Road, Derby DE22 3NE, UK
| | - Priya Daniel
- University Hospitals of Derby and Burton NHS Foundation Trust, Uttoxeter Road, Derby DE22 3NE, UK
| | - Paul Dark
- Salford Royal NHS Foundation Trust, Stott Ln, Salford M6 8HD, UK
- Division of Infection, Immunity and Respiratory Medicine, NIHR Manchester Biomedical Research Centre, University of Manchester, Manchester, M23 9PT, UK
| | - Adam R. Jeans
- Salford Royal NHS Foundation Trust, Stott Ln, Salford M6 8HD, UK
| | - Jamie McCanny
- Guy’s and St Thomas’ NHS Foundation Trust, Great Maze Pond, London SE1 9RT, UK
| | | | - Martin J. Llewelyn
- Brighton and Sussex University Hospitals NHS trust, Eastern Road, Brighton BN2 1ES, UK
| | - Matthias L. Schmid
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Freeman Rd, High Heaton, Newcastle upon Tyne NE7 7DN, UK
| | - Tricia M. McKeever
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Clinical Sciences Building, Nottingham City Hospital Campus, Hucknall Road, Nottingham NG5 1PB, UK
- NIHR Nottingham Biomedical Research Centre, Queen’s Medical Centre, Nottingham NG7 2UH, UK
| | - Martin Beed
- Department of Critical Care, Nottingham University Hospital NHS Trust, Nottingham NG5 1PB, UK
- Division of Anaesthesia, School of Medicine, University of Nottingham, Queens Medical Centre, Derby Rd, Nottingham NG7 2UH, UK
| | - Wei Shen Lim
- Department of Respiratory Medicine, Nottingham University Hospital NHS Trust, Nottingham NG5 1PB, UK
- NIHR Nottingham Biomedical Research Centre, Queen’s Medical Centre, Nottingham NG7 2UH, UK
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Mowbray F, Sivyer K, Santillo M, Jones N, Peto TEA, Walker AS, Llewelyn MJ, Yardley L. Patient engagement with antibiotic messaging in secondary care: a qualitative feasibility study of the ‘review and revise’ experience. Pilot Feasibility Stud 2020; 6:43. [PMID: 32280483 PMCID: PMC7126355 DOI: 10.1186/s40814-020-00590-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 03/24/2020] [Indexed: 01/22/2023] Open
Abstract
Abstract
Background
We aimed to investigate and optimise the acceptability and usefulness of a patient leaflet about antibiotic prescribing decisions made during hospitalisation, and to explore individual patient experiences and preferences regarding the process of antibiotic prescription ‘review and revise’ which is a key strategy to minimise antibiotic overuse in hospitals.
Methods
In this qualitative study, run within the feasibility study of a large, cluster-randomised stepped wedge trial of 36 hospital organisations, a series of semi-structured, think-aloud telephone interviews were conducted and data were analysed using thematic analysis. Fifteen adult patients who had experienced a recent acute medical hospital admission during which they had been prescribed antimicrobials and offered a patient leaflet about antibiotic prescribing were recruited to the study.
Results
Participants reacted positively to the leaflet, reporting that it was both an accessible and important source of information which struck the appropriate balance between informing and reassuring. Participants all valued open communication with clinicians, and were keen to be involved in antibiotic prescribing decisions, with individuals reporting positive experiences regarding antibiotic prescription changes or stopping. Many participants had prior experience or knowledge of antibiotics and resistance, and generally welcomed efforts to reduce antibiotic usage. Overall, there was a feeling that healthcare professionals (HCPs) are trusted experts providing the most appropriate treatment for individual patient conditions.
Conclusions
This study offers novel insights into how patients within secondary care are likely to respond to messages advocating a reduction in the use of antibiotics through the ‘review and revise’ approach. Due to the level of trust that patients place in their care provider, encouraging HCPs within secondary care to engage patients with greater communication and information provision could provide great advantages in the drive to reduce antibiotic use. It may also be beneficial for HCPs to view patient experiences as cumulative events that have the potential to impact future behaviour around antibiotic use. Finally, pre-testing messages about antibiotic prescribing and resistance is vital to dispelling any misconceptions either around effectiveness of treatment for patients, or perceptions of how messages may be received.
Trial registration
Current Controlled Trials ISRCTN12674243 (10 April 2017),
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29
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Santillo M, Sivyer K, Krusche A, Mowbray F, Jones N, Peto TEA, Walker AS, Llewelyn MJ, Yardley L. Intervention planning for Antibiotic Review Kit (ARK): a digital and behavioural intervention to safely review and reduce antibiotic prescriptions in acute and general medicine. J Antimicrob Chemother 2020; 74:3362-3370. [PMID: 31430366 PMCID: PMC6798845 DOI: 10.1093/jac/dkz333] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 05/07/2019] [Accepted: 07/07/2019] [Indexed: 12/11/2022] Open
Abstract
Background Hospital antimicrobial stewardship strategies, such as ‘Start Smart, Then Focus’ in the UK, balance the need for prompt, effective antibiotic treatment with the need to limit antibiotic overuse using ‘review and revise’. However, only a minority of review decisions are to stop antibiotics. Research suggests that this is due to both behavioural and organizational factors. Objectives To develop and optimize the Antibiotic Review Kit (ARK) intervention. ARK is a complex digital, organizational and behavioural intervention that supports implementation of ‘review and revise’ to help healthcare professionals safely stop unnecessary antibiotics. Methods A theory-, evidence- and person-based approach was used to develop and optimize ARK and its implementation. This was done through iterative stakeholder consultation and in-depth qualitative research with doctors, nurses and pharmacists in UK hospitals. Barriers to and facilitators of the intervention and its implementation, and ways to address them, were identified and then used to inform the intervention’s development. Results A key barrier to stopping antibiotics was reportedly a lack of information about the original prescriber’s rationale for and their degree of certainty about the need for antibiotics. An integral component of ARK was the development and optimization of a Decision Aid and its implementation to increase transparency around initial prescribing decisions. Conclusions The key output of this research is a digital and behavioural intervention targeting important barriers to stopping antibiotics at review (see http://bsac-vle.com/ark-the-antibiotic-review-kit/ and http://antibioticreviewkit.org.uk/). ARK will be evaluated in a feasibility study and, if successful, a stepped-wedge cluster-randomized controlled trial at acute hospitals across the NHS.
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Affiliation(s)
- M Santillo
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - K Sivyer
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - A Krusche
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - F Mowbray
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - N Jones
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - T E A Peto
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Nuffield Department of Medicine, University of Oxford, Oxford, UK.,NIHR Biomedical Centre, Oxford, UK
| | - A S Walker
- Nuffield Department of Medicine, University of Oxford, Oxford, UK.,NIHR Biomedical Centre, Oxford, UK
| | - M J Llewelyn
- Brighton and Sussex Medical School, University of Sussex, Falmer, UK
| | - L Yardley
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK.,School of Psychological Science, University of Bristol, Bristol, UK
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30
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Kuehl R, Morata L, Boeing C, Subirana I, Seifert H, Rieg S, Kern WV, Kim HB, Kim ES, Liao CH, Tilley R, Lopez-Cortés LE, Llewelyn MJ, Fowler VG, Thwaites G, Cisneros JM, Scarborough M, Nsutebu E, Gurgui Ferrer M, Pérez JL, Barlow G, Hopkins S, Ternavasio-de la Vega HG, Török ME, Wilson P, Kaasch AJ, Soriano A. Defining persistent Staphylococcus aureus bacteraemia: secondary analysis of a prospective cohort study. Lancet Infect Dis 2020; 20:1409-1417. [PMID: 32763194 DOI: 10.1016/s1473-3099(20)30447-3] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 05/22/2020] [Accepted: 05/27/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Staphylococcus aureus persistent bacteraemia is only vaguely defined and the effect of different durations of bacteraemia on mortality is not well established. Our primary aim was to analyse mortality according to duration of bacteraemia and to derive a clinically relevant definition for persistent bacteraemia. METHODS We did a secondary analysis of a prospective observational cohort study at 17 European centres (nine in the UK, six in Spain, and two in Germany), with recruitment between Jan 1, 2013, and April 30, 2015. Adult patients who were consecutively hospitalised with monomicrobial S aureus bacteraemia were included. Patients were excluded if no follow-up blood culture was taken, if the first follow-up blood-culture was after 7 days, or if active antibiotic therapy was started more than 3 days after first blood culture. The primary outcome was 90-day mortality. Univariable and time-dependent multivariable Cox regression analysis were used to assess predictors of mortality. Duration of bacteraemia was defined as bacteraemic days under active antibiotic therapy counting the first day as day 1. FINDINGS Of 1588 individuals assessed for eligibility, 987 were included (median age 65 years [IQR 51-75]; 625 [63%] male). Death within 90 days occurred in 273 (28%) patients. Patients with more than 1 day of bacteraemia (315 [32%]) had higher Charlson comorbidity index and sequential organ failure assessment scores and a longer interval from first symptom to first blood culture. Crude 90-day mortality increased from 22% (148 of 672) with 1 day of bacteraemia, to 39% (85 of 218) with 2-4 days, 43% (30 of 69) with 5-7 days, and 36% (10 of 28) with more than 7 days of bacteraemia. Metastatic infections developed in 39 (6%) of 672 patients with 1 day of bacteraemia versus 40 (13%) of 315 patients if bacteraemia lasted for at least 2 days. The second day of bacteraemia had the highest HR and earliest cutoff significantly associated with mortality (adjusted hazard ratio 1·93, 95% CI 1·51-2·46; p<0·0001). INTERPRETATION We suggest redefining the cutoff duration for persistent bacteraemia as 2 days or more despite active antibiotic therapy. Our results favour follow-up blood cultures after 24 h for early identification of all patients with increased risk of death and metastatic infection. FUNDING None.
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Affiliation(s)
- Richard Kuehl
- Service of Infectious Diseases, Hospital Clínic of Barcelona, Barcelona, Spain; Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Laura Morata
- Service of Infectious Diseases, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Christian Boeing
- Institute of Medical Microbiology and Hospital Hygiene, Faculty of Medicine, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Isaac Subirana
- CIBER en Epidemiología y Salud Pública, Barcelona, Spain
| | - Harald Seifert
- Institute for Medical Microbiology, Immunology and Hygiene, Faculty of Medicine, University of Cologne, Cologne, Germany; German Center for Infection Research, Partner site Bonn-Cologne, Cologne, Germany
| | - Siegbert Rieg
- Division of Infectious Diseases, Department of Medicine II, Medical Center-University of Freiburg, Freiburg, Germany
| | - Winfried V Kern
- Division of Infectious Diseases, Department of Medicine II, Medical Center-University of Freiburg, Freiburg, Germany
| | - Hong Bin Kim
- Division of Infectious Diseases, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Eu Suk Kim
- Division of Infectious Diseases, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Chun-Hsing Liao
- Infectious Diseases, Department of Internal Medicine, Far Eastern Memorial Hospital, Taipei City, Taiwan
| | - Robert Tilley
- Department of Microbiology, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Luis Eduardo Lopez-Cortés
- Infectious Diseases and Clinical Microbiology Unit, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Martin J Llewelyn
- Department of Infectious Diseases and Microbiology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Vance G Fowler
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Guy Thwaites
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - José Miguel Cisneros
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen del Rocío, CSIC, Universidad de Sevilla, Instituto de Biomedicina de Sevilla, Seville, Spain
| | - Matt Scarborough
- Nuffield Department of Medicine, Oxford University Hospitals NHS Foundation, Oxford, UK
| | - Emmanuel Nsutebu
- Tropical and Infectious Disease Unit, Royal Liverpool University Hospital, Liverpool, UK
| | | | - José L Pérez
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitario Son Espases, Instituto de Investigación Sanitaria Illes Balears, Palma de Mallorca, Spain
| | - Gavin Barlow
- Department of Infection, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | - Susan Hopkins
- Infectious Diseases Unit, Royal Free London NHS Foundation Trust, London, UK
| | | | - M Estée Török
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Peter Wilson
- Department of Microbiology and Virology, University College London Hospital NHS Foundation Trust, London, UK
| | - Achim J Kaasch
- Institute of Medical Microbiology and Hospital Hygiene, Faculty of Medicine, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Alex Soriano
- Service of Infectious Diseases, Hospital Clínic of Barcelona, Barcelona, Spain.
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Cross ELA, Jordan H, Godfrey R, Onakpoya IJ, Shears A, Fidler K, Peto TEA, Walker AS, Llewelyn MJ. Route and duration of antibiotic therapy in acute cellulitis: A systematic review and meta-analysis of the effectiveness and harms of antibiotic treatment. J Infect 2020; 81:521-531. [PMID: 32745638 DOI: 10.1016/j.jinf.2020.07.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 07/25/2020] [Accepted: 07/27/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Compared with guideline recommendations, antibiotic overuse is common in treating cellulitis. We conducted a systematic review and meta-analyses on antibiotic route and duration of treatment for cellulitis in adults and children. METHODS We searched MEDLINE, EMBASE and trial registries from inception to Dec 11, 2019 for interventional and observational studies of antibiotic treatment for cellulitis. Exclusions included case series/reports, pre-septal/orbital cellulitis and non-English language articles. Random-effects meta-analyses were used to produce summary relative risk (RR) estimates for our primary outcome of clinical response. PROSPERO CRD42018100602. RESULTS We included 47/8423 articles, incorporating data from eleven trials (1855 patients) in two meta-analyses. The overall risk of bias was moderate. Only two trials compared the same antibiotic agent in each group. We found no evidence of difference in clinical response rates for antibiotic route or duration (RR(oral:IV)=1.12, 95%CI 0.98-1.27, I2=32% and RR(shorter:longer)=0.99, 95%CI 0•96-1.03, I2 = 0%, respectively). Findings were consistent in observational studies. Follow-up data beyond 30 days were sparse. CONCLUSIONS The evidence base for antibiotic treatment decisions in cellulitis is flawed by biased comparisons, short follow-up and lack of data around harms of antibiotic overuse. Future research should focus on developing patient-tailored antibiotic prescribing for cellulitis to reduce unnecessary antibiotic use.
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Affiliation(s)
- Elizabeth L A Cross
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Falmer, East Sussex BN1 9PS, UK; Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Harriet Jordan
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Rebecca Godfrey
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Igho J Onakpoya
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Annalie Shears
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Katy Fidler
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Falmer, East Sussex BN1 9PS, UK; Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Timothy E A Peto
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK; NIHR Biomedical Centre, Oxford, UK
| | - A Sarah Walker
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK; NIHR Biomedical Centre, Oxford, UK
| | - Martin J Llewelyn
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Falmer, East Sussex BN1 9PS, UK; Brighton and Sussex University Hospitals NHS Trust, Brighton, UK.
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Roope LSJ, Buchanan J, Morrell L, Pouwels KB, Sivyer K, Mowbray F, Abel L, Cross ELA, Yardley L, Peto T, Walker AS, Llewelyn MJ, Wordsworth S. Why do hospital prescribers continue antibiotics when it is safe to stop? Results of a choice experiment survey. BMC Med 2020; 18:196. [PMID: 32727604 PMCID: PMC7391515 DOI: 10.1186/s12916-020-01660-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 06/08/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Deciding whether to discontinue antibiotics at early review is a cornerstone of hospital antimicrobial stewardship practice worldwide. In England, this approach is described in government guidance ('Start Smart then Focus'). However, < 10% of hospital antibiotic prescriptions are discontinued at review, despite evidence that 20-30% could be discontinued safely. We aimed to quantify the relative importance of factors influencing prescriber decision-making at review. METHODS We conducted an online choice experiment, a survey method to elicit preferences. Acute/general hospital prescribers in England were asked if they would continue or discontinue antibiotic treatment in 15 hypothetical scenarios. Scenarios were described according to six attributes, including patients' presenting symptoms and whether discontinuation would conflict with local prescribing guidelines. Respondents' choices were analysed using conditional logistic regression. RESULTS One hundred respondents completed the survey. Respondents were more likely to continue antibiotics when discontinuation would 'strongly conflict' with local guidelines (average marginal effect (AME) on the probability of continuing + 0.194 (p < 0.001)), when presenting symptoms more clearly indicated antibiotics (AME of urinary tract infection symptoms + 0.173 (p < 0.001) versus unclear symptoms) and when patients had severe frailty/comorbidities (AME = + 0.101 (p < 0.001)). Respondents were less likely to continue antibiotics when under no external pressure to continue (AME = - 0.101 (p < 0.001)). Decisions were also influenced by the risks to patient health of continuing/discontinuing antibiotic treatment. CONCLUSIONS Guidelines that conflict with antibiotic discontinuation (e.g. pre-specify fixed durations) may discourage safe discontinuation at review. In contrast, guidelines conditional on patient factors/treatment response could help hospital prescribers discontinue antibiotics if diagnostic information suggesting they are no longer needed is available.
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Affiliation(s)
- Laurence S J Roope
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK. .,NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, University of Oxford, Oxford, UK. .,NIHR Health Protection Research Unit (HPRU) in Healthcare Associated Infections and Antimicrobial Resistance at the University of Oxford in partnership with Public Health England (PHE), Oxford, UK.
| | - James Buchanan
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK.,NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, University of Oxford, Oxford, UK.,NIHR Health Protection Research Unit (HPRU) in Healthcare Associated Infections and Antimicrobial Resistance at the University of Oxford in partnership with Public Health England (PHE), Oxford, UK
| | - Liz Morrell
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK
| | - Koen B Pouwels
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK.,NIHR Health Protection Research Unit (HPRU) in Healthcare Associated Infections and Antimicrobial Resistance at the University of Oxford in partnership with Public Health England (PHE), Oxford, UK
| | - Katy Sivyer
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - Fiona Mowbray
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - Lucy Abel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Elizabeth L A Cross
- Department of Microbiology and Infection, Brighton and Sussex University Hospitals NHS Trust, Eastern Road, Brighton, UK
| | - Lucy Yardley
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK.,School of Psychological Science, University of Bristol, Clifton, UK
| | - Tim Peto
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, University of Oxford, Oxford, UK.,Nuffield Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK.,Oxford University Hospitals NHS Trust, Oxford, UK
| | - A Sarah Walker
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, University of Oxford, Oxford, UK.,NIHR Health Protection Research Unit (HPRU) in Healthcare Associated Infections and Antimicrobial Resistance at the University of Oxford in partnership with Public Health England (PHE), Oxford, UK.,Nuffield Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Martin J Llewelyn
- Department of Microbiology and Infection, Brighton and Sussex University Hospitals NHS Trust, Eastern Road, Brighton, UK.,Brighton and Sussex Medical School, Brighton, UK
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK.,NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, University of Oxford, Oxford, UK
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Stoneham SM, Cantillon DM, Waddell SJ, Llewelyn MJ. Spontaneously Occurring Small-Colony Variants of Staphylococcus aureus Show Enhanced Clearance by THP-1 Macrophages. Front Microbiol 2020; 11:1300. [PMID: 32595630 PMCID: PMC7303551 DOI: 10.3389/fmicb.2020.01300] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 05/20/2020] [Indexed: 11/20/2022] Open
Abstract
Staphylococcus aureus is a common cause of chronic and relapsing infection, especially when the ability of the immune system to sterilize a focus of infection is compromised (e.g., because of a foreign body or in the cystic fibrosis lung). Chronic infections are associated with slow-growing colony phenotypes of S. aureus on solid media termed small-colony variants (SCVs). Stable SCVs show characteristic mutations in the electron transport chain that convey resistance to antibiotics, particularly aminoglycosides. This can be used to identify SCVs from within mixed-colony phenotype populations of S. aureus. More recently, populations of SCVs that rapidly revert to a “wild-type” (WT) colony phenotype, in the absence of selection pressure, have also been described. In laboratory studies, SCVs accumulate through prolonged infection of non-professional phagocytes and may represent an adaptation to the intracellular environment. However, data from phagocytic cells are lacking. In this study, we mapped SCV and WT colony populations in axenic growth of multiple well-characterized methicillin-sensitive and methicillin-resistant S. aureus strains. We identified SCVs populations on solid media both in the presence and absence of gentamicin. We generated stable SCVs from Newman strain S. aureus, and infected human macrophages with WT S. aureus (Newman, 8325-4) and their SCV counterparts (SCV3, I10) to examine intracellular formation and survival of SCVs. We show that SCVs arise spontaneously during axenic growth, and that the ratio of SCV:WT morphology differs between strains. Exposure to the intracellular environment of human macrophages did not increase formation of SCVs over 5 days and macrophages were able to clear stable SCV bacteria more effectively than their WT counterparts.
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Affiliation(s)
- Simon M Stoneham
- Department of Microbiology and Infection, Royal Sussex County Hospital, Brighton, United Kingdom.,Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom
| | - Daire M Cantillon
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom
| | - Simon J Waddell
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom
| | - Martin J Llewelyn
- Department of Microbiology and Infection, Royal Sussex County Hospital, Brighton, United Kingdom.,Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom
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Mott DJ, Hampson G, Llewelyn MJ, Mestre-Ferrandiz J, Hopkins MM. Authors' Reply to Hays: "A Multinational European Study of Patient Preferences for Novel Diagnostics to Manage Antimicrobial Resistance". Appl Health Econ Health Policy 2020; 18:459-460. [PMID: 32201931 DOI: 10.1007/s40258-020-00573-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- David J Mott
- Office of Health Economics, Southside, 7th Floor, 105 Victoria Street, London, UK.
| | - Grace Hampson
- Office of Health Economics, Southside, 7th Floor, 105 Victoria Street, London, UK
| | | | - Jorge Mestre-Ferrandiz
- Office of Health Economics, Southside, 7th Floor, 105 Victoria Street, London, UK
- Independent Economics Consultant, Madrid, Spain
| | - Michael M Hopkins
- Science Policy Research Unit, University of Sussex Business School, Jubilee Building, Falmer, Brighton, UK
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Affiliation(s)
- George Edwards
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Oxford, UK
| | - Karoline Freeman
- Warwick Medical School, Division of Health Sciences, University of Warwick, Coventry, UK
| | | | - Gail Hayward
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Oxford, UK
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36
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Hamilton WL, Pires SM, Lippett S, Gudka V, Cross ELA, Llewelyn MJ. The impact of diagnostic microbiology on de-escalation of antimicrobial therapy in hospitalised adults. BMC Infect Dis 2020; 20:102. [PMID: 32013908 PMCID: PMC6998081 DOI: 10.1186/s12879-020-4823-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 01/24/2020] [Indexed: 12/31/2022] Open
Abstract
Background Minimising antimicrobial overuse is needed to limit antimicrobial resistance. There is little evidence on how often microbiological testing informs antimicrobial de-escalation (e.g. stopping, shortening duration, switching to narrower spectrum or intravenous to oral switch) at 48–72 h “review and revise”. We performed a patient level analysis of diagnostic microbiology and antimicrobial prescribing to determine the impact of microbiology results on antimicrobial review outcomes. Methods Antimicrobial prescribing data were collected for hospitalised adults from across Brighton and Sussex University Hospitals NHS Trust using routine monthly audits of prescribing practice from July 2016 to April 2017. Microbiology testing data for cultures of blood, urine, sputum and cerebrospinal fluid (CSF) were gathered from the hospital pathology database and linked to prescriptions with matching patient identification codes. Antimicrobial prescriptions were grouped into “prescription episodes” (PEs), defined as one or more antimicrobials prescribed to the same patient for the same indication. Medical records were reviewed for all PEs with positive microbiology and a randomised sample of those with negative results to assess the impact of the microbiology result on the antimicrobial prescription(s). Results After excluding topical and prophylactic prescriptions, data were available for 382 inpatient antimicrobial prescriptions grouped into 276 prescription episodes. 162/276 (59%) had contemporaneous microbiology sent. After filtering likely contaminants, 33/276 (12%) returned relevant positive results, of which 20/33 (61%) had antimicrobials changed from empiric therapy as a result with 6/33 (18%) prompting de-escalation. Positive blood and CSF tended to have greater impact than urine or sputum cultures. 124/276 (45%) PEs returned only negative microbiology, and this was documented in the medical notes less often (9/40, 23%) than positive results (28/33, 85%). Out of 40 reviewed PEs with negative microbiology, we identified just one (~ 3%) in which antimicrobials were unambiguously de-escalated following the negative result. Conclusions The majority of diagnostic microbiology tests sent to inform clinical management yielded negative results. However, negative microbiology contributed little to clinical decision making about antimicrobial de-escalation, perhaps reflecting a lack of trust in negative results by treating clinicians. Improving the negative predictive value of currently available diagnostic microbiology could help hospital prescribers in de-escalating antimicrobial therapy.
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Affiliation(s)
- William L Hamilton
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK.,Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Samantha Lippett
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Vikesh Gudka
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Elizabeth L A Cross
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK.,Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Martin J Llewelyn
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK. .,Brighton and Sussex Medical School, University of Sussex, Brighton, UK.
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37
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Mott DJ, Hampson G, Llewelyn MJ, Mestre-Ferrandiz J, Hopkins MM. A Multinational European Study of Patient Preferences for Novel Diagnostics to Manage Antimicrobial Resistance. Appl Health Econ Health Policy 2020; 18:69-79. [PMID: 31541361 PMCID: PMC6978300 DOI: 10.1007/s40258-019-00516-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
BACKGROUND Novel diagnostics are needed to manage antimicrobial resistance (AMR). Patient preferences are important in determining whether diagnostic tests are successful in practice, but there are few data describing the test attributes which matter most to patients. We elicited patients' preferences for attributes of diagnostic tests that could be used to reduce unnecessary antibiotic use in primary care across seven European countries. METHODS We used an online stated preference survey, including a discrete choice experiment (DCE). The DCE explored how patients make trade-offs between three key attributes of diagnostic tests: the speed that results were available, confidence in the test results, and how convenient it is to take the test. Individuals were eligible to complete the survey if they had taken antibiotics within the last 2 years and were resident in Germany, Italy, Spain, France, Greece, the Netherlands or the United Kingdom (UK). RESULTS In total, 988 respondents completed the survey. The DCE responses illustrated that speed was the least important attribute in most countries. Responses from Germany and the Netherlands indicated that confidence was most important in these countries. Responses from the UK, France, Spain and Italy showed convenience as the most important attribute in these countries. Two attributes, confidence and convenience, were jointly favoured by respondents in Greece. CONCLUSION Patients in different European countries do not have the same preferences for the attributes of diagnostic tests to manage AMR in primary care. Failure to account for such differences during test development could reduce test uptake, result in continued overuse of antibiotics, and hamper marketisation.
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Affiliation(s)
- David J Mott
- Office of Health Economics, Southside, 7th Floor, 105 Victoria Street, London, UK.
| | - Grace Hampson
- Office of Health Economics, Southside, 7th Floor, 105 Victoria Street, London, UK
| | | | - Jorge Mestre-Ferrandiz
- Office of Health Economics, Southside, 7th Floor, 105 Victoria Street, London, UK
- Independent Economics Consultant, Madrid, Spain
| | - Michael M Hopkins
- Science Policy Research Unit, University of Sussex Business School, Jubilee Building, Falmer, Brighton, UK
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38
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Knight GM, Davies NG, Colijn C, Coll F, Donker T, Gifford DR, Glover RE, Jit M, Klemm E, Lehtinen S, Lindsay JA, Lipsitch M, Llewelyn MJ, Mateus ALP, Robotham JV, Sharland M, Stekel D, Yakob L, Atkins KE. Mathematical modelling for antibiotic resistance control policy: do we know enough? BMC Infect Dis 2019; 19:1011. [PMID: 31783803 PMCID: PMC6884858 DOI: 10.1186/s12879-019-4630-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 11/11/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Antibiotics remain the cornerstone of modern medicine. Yet there exists an inherent dilemma in their use: we are able to prevent harm by administering antibiotic treatment as necessary to both humans and animals, but we must be mindful of limiting the spread of resistance and safeguarding the efficacy of antibiotics for current and future generations. Policies that strike the right balance must be informed by a transparent rationale that relies on a robust evidence base. MAIN TEXT One way to generate the evidence base needed to inform policies for managing antibiotic resistance is by using mathematical models. These models can distil the key drivers of the dynamics of resistance transmission from complex infection and evolutionary processes, as well as predict likely responses to policy change in silico. Here, we ask whether we know enough about antibiotic resistance for mathematical modelling to robustly and effectively inform policy. We consider in turn the challenges associated with capturing antibiotic resistance evolution using mathematical models, and with translating mathematical modelling evidence into policy. CONCLUSIONS We suggest that in spite of promising advances, we lack a complete understanding of key principles. From this we advocate for priority areas of future empirical and theoretical research.
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Affiliation(s)
- Gwenan M Knight
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine (LSHTM), London, UK.
| | - Nicholas G Davies
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine (LSHTM), London, UK
| | - Caroline Colijn
- Department of Mathematics, Simon Fraser University, Burnaby, Canada
| | - Francesc Coll
- Department of Infection Biology, Faculty of Infectious and Tropical Diseases, LSHTM, London, UK
| | - Tjibbe Donker
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Danna R Gifford
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Rebecca E Glover
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, LSHTM, London, UK
| | - Mark Jit
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine (LSHTM), London, UK
| | | | - Sonja Lehtinen
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Jodi A Lindsay
- Institute for Infection and Immunity, St George's, University of London, Cranmer Terrace, London, UK
| | - Marc Lipsitch
- Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Martin J Llewelyn
- Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton, UK
| | - Ana L P Mateus
- Population Sciences and Pathobiology Department, Royal Veterinary College, London, UK
| | - Julie V Robotham
- Modelling and Economics Unit, National Infection Service, Public Health England, London, UK
| | - Mike Sharland
- Paediatric Infectious Disease Research Group, St George's University of London, London, UK
| | - Dov Stekel
- School of Biosciences, University of Nottingham, Loughborough, UK
| | - Laith Yakob
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, LSHTM, London, UK
| | - Katherine E Atkins
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine (LSHTM), London, UK
- Centre for Global Health Research, Usher Institute for Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
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39
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Peto L, Fawcett NJ, Crook DW, Peto TEA, Llewelyn MJ, Walker AS. Selective culture enrichment and sequencing of feces to enhance detection of antimicrobial resistance genes in third-generation cephalosporin resistant Enterobacteriaceae. PLoS One 2019; 14:e0222831. [PMID: 31703058 PMCID: PMC6839868 DOI: 10.1371/journal.pone.0222831] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 09/07/2019] [Indexed: 01/02/2023] Open
Abstract
Metagenomic sequencing of fecal DNA can usefully characterise an individual's intestinal resistome but is limited by its inability to detect important pathogens that may be present at low abundance, such as carbapenemase or extended-spectrum beta-lactamase producing Enterobacteriaceae. Here we aimed to develop a hybrid protocol to improve detection of resistance genes in Enterobacteriaceae by using a short period of culture enrichment prior to sequencing of DNA extracted directly from the enriched sample. Volunteer feces were spiked with carbapenemase-producing Enterobacteriaceae and incubated in selective broth culture for 6 hours before sequencing. Different DNA extraction methods were compared, including a plasmid extraction protocol to increase the detection of plasmid-associated resistance genes. Although enrichment prior to sequencing increased the detection of carbapenemase genes, the differing growth characteristics of the spike organisms precluded accurate quantification of their concentration prior to culture. Plasmid extraction increased detection of resistance genes present on plasmids, but the effects were heterogeneous and dependent on plasmid size. Our results demonstrate methods of improving the limit of detection of selected resistance mechanisms in a fecal resistome assay, but they also highlight the difficulties in using these techniques for accurate quantification and should inform future efforts to achieve this goal.
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Affiliation(s)
- Leon Peto
- National Institute for Health Research (NIHR) Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance, John Radcliffe Hospital, Oxford, England, United Kingdom
- Nuffield Department of Medicine, University of Oxford, Oxford, England, United Kingdom
- * E-mail:
| | - Nicola J. Fawcett
- National Institute for Health Research (NIHR) Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance, John Radcliffe Hospital, Oxford, England, United Kingdom
- Nuffield Department of Medicine, University of Oxford, Oxford, England, United Kingdom
| | - Derrick W. Crook
- National Institute for Health Research (NIHR) Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance, John Radcliffe Hospital, Oxford, England, United Kingdom
- Nuffield Department of Medicine, University of Oxford, Oxford, England, United Kingdom
- National Infection Service, Public Health England, Colindale, London, England, United Kingdom
| | - Tim E. A. Peto
- National Institute for Health Research (NIHR) Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance, John Radcliffe Hospital, Oxford, England, United Kingdom
- Nuffield Department of Medicine, University of Oxford, Oxford, England, United Kingdom
| | - Martin J. Llewelyn
- Department of Global Health and Infection, Brighton and Sussex Medical School, Falmer, Sussex, England, United Kingdom
- Department of Microbiology and Infection, Brighton and Sussex University Hospitals NHS Trust, Brighton, England, United Kingdom
| | - A. Sarah Walker
- National Institute for Health Research (NIHR) Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance, John Radcliffe Hospital, Oxford, England, United Kingdom
- Nuffield Department of Medicine, University of Oxford, Oxford, England, United Kingdom
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40
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Szubert A, Bailey SL, Cooke GS, Peto T, Llewelyn MJ, Edgeworth JD, Walker AS, Thwaites GE. Predictors of recurrence, early treatment failure and death from Staphylococcus aureus bacteraemia: Observational analyses within the ARREST trial. J Infect 2019; 79:332-340. [DOI: 10.1016/j.jinf.2019.08.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 07/26/2019] [Accepted: 08/03/2019] [Indexed: 02/05/2023]
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Islam J, Ashiru-Oredope D, Budd E, Howard P, Walker AS, Hopkins S, Llewelyn MJ. A national quality incentive scheme to reduce antibiotic overuse in hospitals: evaluation of perceptions and impact. J Antimicrob Chemother 2019; 73:1708-1713. [PMID: 29506043 DOI: 10.1093/jac/dky041] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 01/20/2018] [Indexed: 11/13/2022] Open
Abstract
Background In 2016/2017, a financially linked antibiotic prescribing quality improvement initiative Commissioning for Quality and Innovation (AMR-CQUIN) was introduced across acute hospitals in England. This aimed for >1% reductions in DDDs/1000 admissions of total antibiotics, piperacillin/tazobactam and carbapenems compared with 2013/2014 and improved review of empirical antibiotic prescriptions. Objectives To assess perceptions of staff leading antimicrobial stewardship activity regarding the AMR-CQUIN, the investments made by hospitals to achieve it and how these related to achieving reductions in antibiotic use. Methods We invited antimicrobial stewardship leads at acute hospitals across England to complete a web-based survey. Antibiotic prescribing data were downloaded from the PHE Antimicrobial Resistance Local Indicators resource. Results Responses were received from 116/155 (75%) acute hospitals. Owing to yearly increases in antibiotic use, most trusts needed to make >5% reductions in antibiotic consumption to achieve the AMR-CQUIN goal of 1% reduction. Additional funding was made available at 23/113 (20%) trusts and, in 18 (78%), this was <10% of the AMR-CQUIN value. Nationally, the annual trend for increased antibiotic use reversed in 2016/2017. In 2014/2015, year-on-year changes were +3.7% (IQR -0.8%, +8.4%), +9.4% (+0.2%, +19.5%) and +5.8% (-6.2%, +18.2%) for total antibiotics, piperacillin/tazobactam and carbapenems, respectively, and +0.1% (-5.4%, +4.0%), -4.8% (-16.9%, +3.2%) and -8.0% (-20.2%, +4.0%) in 2016/2017. Hospitals where staff believed they could reduce antibiotic use were more likely to do so (P < 0.001). Conclusions Introducing the AMR-CQUIN was associated with a reduction in antibiotic use. For individual hospitals, achieving the AMR-CQUIN was associated with favourable perceptions of staff and not availability of funding.
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Affiliation(s)
- J Islam
- Department of Microbiology and Infection, Brighton and Sussex University Hospitals NHS Trust, Brighton BN2 5BE, UK.,Department of Global Health and Infection, Brighton and Sussex Medical School, Falmer BN1 9PS, UK
| | - D Ashiru-Oredope
- AMR Programme, Public Health England, Wellington House, 133-155 Waterloo Rd, London SE1 8UG, UK
| | - E Budd
- AMR Programme, Public Health England, Wellington House, 133-155 Waterloo Rd, London SE1 8UG, UK
| | - P Howard
- Department of Medicines Management and Pharmacy, Leeds Teaching Hospitals NHS Trust, Leeds LS9 7TF, UK.,Faculty of Medicine and Health, University of Leeds, Leeds LS2 9JT, UK
| | - A S Walker
- Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - S Hopkins
- AMR Programme, Public Health England, Wellington House, 133-155 Waterloo Rd, London SE1 8UG, UK
| | - M J Llewelyn
- Department of Microbiology and Infection, Brighton and Sussex University Hospitals NHS Trust, Brighton BN2 5BE, UK.,Department of Global Health and Infection, Brighton and Sussex Medical School, Falmer BN1 9PS, UK
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42
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Schweitzer VA, van Werkhoven CH, Rodríguez Baño J, Bielicki J, Harbarth S, Hulscher M, Huttner B, Islam J, Little P, Pulcini C, Savoldi A, Tacconelli E, Timsit JF, van Smeden M, Wolkewitz M, Bonten MJM, Walker AS, Llewelyn MJ. Optimizing design of research to evaluate antibiotic stewardship interventions: consensus recommendations of a multinational working group. Clin Microbiol Infect 2019; 26:41-50. [PMID: 31493472 DOI: 10.1016/j.cmi.2019.08.017] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 08/20/2019] [Accepted: 08/22/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Antimicrobial stewardship interventions and programmes aim to ensure effective treatment while minimizing antimicrobial-associated harms including resistance. Practice in this vital area is undermined by the poor quality of research addressing both what specific antimicrobial use interventions are effective and how antimicrobial use improvement strategies can be implemented into practice. In 2016 we established a working party to identify the key design features that limit translation of existing research into practice and then to make recommendations for how future studies in this field should be optimally designed. The first part of this work has been published as a systematic review. Here we present the working group's final recommendations. METHODS An international working group for design of antimicrobial stewardship intervention evaluations was convened in response to the fourth call for leading expert network proposals by the Joint Programming Initiative on Antimicrobial Resistance (JPIAMR). The group comprised clinical and academic specialists in antimicrobial stewardship and clinical trial design from six European countries. Group members completed a structured questionnaire to establish the scope of work and key issues to develop ahead of a first face-to-face meeting that (a) identified the need for a comprehensive systematic review of study designs in the literature and (b) prioritized key areas where research design considerations restrict translation of findings into practice. The working group's initial outputs were reviewed by independent advisors and additional expertise was sought in specific clinical areas. At a second face-to-face meeting the working group developed a theoretical framework and specific recommendations to support optimal study design. These were finalized by the working group co-ordinators and agreed by all working group members. RESULTS We propose a theoretical framework in which consideration of the intervention rationale the intervention setting, intervention features and the intervention aims inform selection and prioritization of outcome measures, whether the research sets out to determine superiority or non-inferiority of the intervention measured by its primary outcome(s), the most appropriate study design (e.g. experimental or quasi- experimental) and the detailed design features. We make 18 specific recommendation in three domains: outcomes, objectives and study design. CONCLUSIONS Researchers, funders and practitioners will be able to draw on our recommendations to most efficiently evaluate antimicrobial stewardship interventions.
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Affiliation(s)
- V A Schweitzer
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, the Netherlands
| | - C H van Werkhoven
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, the Netherlands
| | - J Rodríguez Baño
- Unit of Infectious Diseases, Clinical Microbiology and Preventive Medicine, Department of Medicine, Hospital Universitario Virgen Macarena, Universidad de Sevilla and Biomedicine Institute of Sevilla (IBiS), Seville, Spain
| | - J Bielicki
- Paediatric Infectious Disease Research Group, St George's University of London, London, UK
| | - S Harbarth
- Department of Infectious Diseases and Infection Control, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - M Hulscher
- Scientific Centre for Quality of Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - B Huttner
- Department of Infectious Diseases and Infection Control, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - J Islam
- Department of Global Health and Infection, Brighton and Sussex Medical School, Falmer, UK
| | - P Little
- Department of Primary Care Research, University of Southampton, Southampton, UK
| | - C Pulcini
- Infectious Diseases Department, Université de Lorraine, CHRU-Nancy, APEMAC, Université de Lorraine, Nancy, France
| | - A Savoldi
- Infectious Diseases, Department of Diagnostic and Public Health, Verona, Italy; University Hospital, Internal Medicine, Tuebingen University, Germany
| | - E Tacconelli
- Infectious Diseases, Department of Diagnostic and Public Health, Verona, Italy; University Hospital, Internal Medicine, Tuebingen University, Germany
| | - J-F Timsit
- Medical and Infectious Diseases ICU, Bichat University Hospital, AP-HP, Paris, France; UMR 1137, Infection Antimicrobials Modelling Evolution, Paris Diderot University, Paris, France
| | - M van Smeden
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - M Wolkewitz
- Institute for Medical Biometry and Statistics, University of Freiburg, Freiburg, Germany
| | - M J M Bonten
- Department of Medical Microbiology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - A S Walker
- MRC Clinical Trials Unit, University College London, London, UK; Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - M J Llewelyn
- Department of Primary Care Research, University of Southampton, Southampton, UK.
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Cross ELA, Sivyer K, Islam J, Santillo M, Mowbray F, Peto TEA, Walker AS, Yardley L, Llewelyn MJ. Adaptation and implementation of the ARK (Antibiotic Review Kit) intervention to safely and substantially reduce antibiotic use in hospitals: a feasibility study. J Hosp Infect 2019; 103:268-275. [PMID: 31394146 DOI: 10.1016/j.jhin.2019.07.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 07/30/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Antimicrobial stewardship initiatives in secondary care depend on clinicians undertaking antibiotic prescription reviews but decisions to limit antibiotic treatment at review are complex. AIM To assess the feasibility and acceptability of implementing ARK (Antibiotic Review Kit), a behaviour change intervention made up of four components (brief online tool, prescribing decision aid, regular data collection and feedback process, and patient leaflet) to support stopping antibiotic treatment when it is safe to do so among hospitalized patients; before definitive evaluation through a stepped-wedge cluster-randomized controlled trial. METHODS Acceptability of the different intervention elements was assessed for a period of 12 weeks by uptake of the online tool, adoption of the decision aid into prescribing practice, and rates of decisions to stop antibiotics at review (assessed through repeated point-prevalence surveys). Patient perceptions of the information leaflet were assessed through a brief questionnaire. FINDINGS All elements of the intervention were successfully introduced into practice. A total of 132 staff encompassing a broad range of prescribers and non-prescribers completed the online tool (19.4 per 100 acute beds), including 97% (32/33) of the pre-specified essential clinical staff. Among 588 prescription charts evaluated in seven point-prevalence surveys over the 12-week implementation period, 82% overall (76-90% at each survey) used the decision aid. The median antibiotic stop rate post implementation was 36% (range: 29-40% at each survey) compared with 9% pre implementation (P < 0.001). CONCLUSION ARK provides a feasible and acceptable mechanism to support stopping antibiotics safely at post-prescription reviews in an acute hospital setting.
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Affiliation(s)
- E L A Cross
- Brighton and Sussex Medical School, University of Sussex, Falmer, UK
| | - K Sivyer
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - J Islam
- Brighton and Sussex Medical School, University of Sussex, Falmer, UK
| | - M Santillo
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - F Mowbray
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - T E A Peto
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Nuffield Department of Medicine, University of Oxford, Oxford, UK; NIHR Biomedical Centre, Oxford, UK
| | - A S Walker
- Nuffield Department of Medicine, University of Oxford, Oxford, UK; NIHR Biomedical Centre, Oxford, UK
| | - L Yardley
- School of Psychological Science, University of Bristol, Bristol, UK
| | - M J Llewelyn
- Brighton and Sussex Medical School, University of Sussex, Falmer, UK.
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Walker AS, Budgell E, Laskawiec-Szkonter M, Sivyer K, Wordsworth S, Quaddy J, Santillo M, Krusche A, Roope LSJ, Bright N, Mowbray F, Jones N, Hand K, Rahman N, Dobson M, Hedley E, Crook D, Sharland M, Roseveare C, Hobbs FDR, Butler C, Vaughan L, Hopkins S, Yardley L, Peto TEA, Llewelyn MJ. Antibiotic Review Kit for Hospitals (ARK-Hospital): study protocol for a stepped-wedge cluster-randomised controlled trial. Trials 2019; 20:421. [PMID: 31296255 PMCID: PMC6625068 DOI: 10.1186/s13063-019-3497-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 06/05/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND To ensure patients continue to get early access to antibiotics at admission, while also safely reducing antibiotic use in hospitals, one needs to target the continued need for antibiotics as more diagnostic information becomes available. UK Department of Health guidance promotes an initiative called 'Start Smart then Focus': early effective antibiotics followed by active 'review and revision' 24-72 h later. However in 2017, < 10% of antibiotic prescriptions were discontinued at review, despite studies suggesting that 20-30% of prescriptions could be stopped safely. METHODS/DESIGN Antibiotic Review Kit for Hospitals (ARK-Hospital) is a complex 'review and revise' behavioural intervention targeting healthcare professionals involved in antibiotic prescribing or administration in inpatients admitted to acute/general medicine (the largest consumers of non-prophylactic antibiotics in hospitals). The primary study objective is to evaluate whether ARK-Hospital can safely reduce the total antibiotic burden in acute/general medical inpatients by at least 15%. The primary hypotheses are therefore that the introduction of the behavioural intervention will be non-inferior in terms of 30-day mortality post-admission (relative margin 5%) for an acute/general medical inpatient, and superior in terms of defined daily doses of antibiotics per acute/general medical admission (co-primary outcomes). The unit of observation is a hospital organisation, a single hospital or group of hospitals organised with one executive board and governance framework (National Health Service trusts in England; health boards in Northern Ireland, Wales and Scotland). The study comprises a feasibility study in one organisation (phase I), an internal pilot trial in three organisations (phase II) and a cluster (organisation)-randomised stepped-wedge trial (phase III) targeting a minimum of 36 organisations in total. Randomisation will occur over 18 months from November 2017 with a further 12 months follow-up to assess sustainability. The behavioural intervention will be delivered to healthcare professionals involved in antibiotic prescribing or administration in adult inpatients admitted to acute/general medicine. Outcomes will be assessed in adult inpatients admitted to acute/general medicine, collected through routine electronic health records in all patients. DISCUSSION ARK-Hospital aims to provide a feasible, sustainable and generalisable mechanism for increasing antibiotic stopping in patients who no longer need to receive them at 'review and revise'. TRIAL REGISTRATION ISRCTN Current Controlled Trials, ISRCTN12674243 . Registered on 10 April 2017.
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Affiliation(s)
- Ann Sarah Walker
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Eric Budgell
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Magda Laskawiec-Szkonter
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Katy Sivyer
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jack Quaddy
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Marta Santillo
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - Adele Krusche
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - Laurence S. J. Roope
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Nicole Bright
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Fiona Mowbray
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - Nicola Jones
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Kieran Hand
- University of Southampton, Southampton, UK
- University Hospital Southampton NHS Trust, Southampton, UK
| | - Najib Rahman
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Melissa Dobson
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Emma Hedley
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Derrick Crook
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | | | - F. D. Richard Hobbs
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Chris Butler
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Susan Hopkins
- Royal Free London NHS Foundation Trust, London, UK
- National Infection Service, Public Health England, London, UK
| | - Lucy Yardley
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
- School of Psychological Science, University of Bristol, Clifton, UK
| | - Timothy E. A. Peto
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - on behalf of the ARK trial team
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- University of Southampton, Southampton, UK
- University Hospital Southampton NHS Trust, Southampton, UK
- St George’s, University of London, London, UK
- Southern Health NHS Foundation Trust, Southampton, UK
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- The Nuffield Trust, London, UK
- Royal Free London NHS Foundation Trust, London, UK
- School of Psychological Science, University of Bristol, Clifton, UK
- National Infection Service, Public Health England, London, UK
- Brighton and Sussex Medical School, Brighton, UK
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Thwaites GE, Scarborough M, Szubert A, Saramago Goncalves P, Soares M, Bostock J, Nsutebu E, Tilley R, Cunningham R, Greig J, Wyllie SA, Wilson P, Auckland C, Cairns J, Ward D, Lal P, Guleri A, Jenkins N, Sutton J, Wiselka M, Armando GR, Graham C, Chadwick PR, Barlow G, Gordon NC, Young B, Meisner S, McWhinney P, Price DA, Harvey D, Nayar D, Jeyaratnam D, Planche T, Minton J, Hudson F, Hopkins S, Williams J, Török ME, Llewelyn MJ, Edgeworth JD, Walker AS. Adjunctive rifampicin to reduce early mortality from Staphylococcus aureus bacteraemia: the ARREST RCT. Health Technol Assess 2019; 22:1-148. [PMID: 30382016 DOI: 10.3310/hta22590] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Staphylococcus aureus bacteraemia is a common and frequently fatal infection. Adjunctive rifampicin may enhance early S. aureus killing, sterilise infected foci and blood faster, and thereby reduce the risk of dissemination, metastatic infection and death. OBJECTIVES To determine whether or not adjunctive rifampicin reduces bacteriological (microbiologically confirmed) failure/recurrence or death through 12 weeks from randomisation. Secondary objectives included evaluating the impact of rifampicin on all-cause mortality, clinically defined failure/recurrence or death, toxicity, resistance emergence, and duration of bacteraemia; and assessing the cost-effectiveness of rifampicin. DESIGN Parallel-group, randomised (1 : 1), blinded, placebo-controlled multicentre trial. SETTING UK NHS trust hospitals. PARTICIPANTS Adult inpatients (≥ 18 years) with meticillin-resistant or susceptible S. aureus grown from one or more blood cultures, who had received < 96 hours of antibiotic therapy for the current infection, and without contraindications to rifampicin. INTERVENTIONS Adjunctive rifampicin (600-900 mg/day, oral or intravenous) or placebo for 14 days in addition to standard antibiotic therapy. Investigators and patients were blinded to trial treatment. Follow-up was for 12 weeks (assessments at 3, 7, 10 and 14 days, weekly until discharge and final assessment at 12 weeks post randomisation). MAIN OUTCOME MEASURES The primary outcome was all-cause bacteriological (microbiologically confirmed) failure/recurrence or death through 12 weeks from randomisation. RESULTS Between December 2012 and October 2016, 758 eligible participants from 29 UK hospitals were randomised: 370 to rifampicin and 388 to placebo. The median age was 65 years [interquartile range (IQR) 50-76 years]. A total of 485 (64.0%) infections were community acquired and 132 (17.4%) were nosocomial; 47 (6.2%) were caused by meticillin-resistant S. aureus. A total of 301 (39.7%) participants had an initial deep infection focus. Standard antibiotics were given for a median of 29 days (IQR 18-45 days) and 619 (81.7%) participants received flucloxacillin. By 12 weeks, 62 out of 370 (16.8%) patients taking rifampicin versus 71 out of 388 (18.3%) participants taking the placebo experienced bacteriological (microbiologically confirmed) failure/recurrence or died [absolute risk difference -1.4%, 95% confidence interval (CI) -7.0% to 4.3%; hazard ratio 0.96, 95% CI 0.68 to 1.35; p = 0.81]. There were 4 (1.1%) and 5 (1.3%) bacteriological failures (p = 0.82) in the rifampicin and placebo groups, respectively. There were 3 (0.8%) versus 16 (4.1%) bacteriological recurrences (p = 0.01), and 55 (14.9%) versus 50 (12.9%) deaths without bacteriological failure/recurrence (p = 0.30) in the rifampicin and placebo groups, respectively. Over 12 weeks, there was no evidence of differences in clinically defined failure/recurrence/death (p = 0.84), all-cause mortality (p = 0.60), serious (p = 0.17) or grade 3/4 (p = 0.36) adverse events (AEs). However, 63 (17.0%) participants in the rifampicin group versus 39 (10.1%) participants in the placebo group experienced antibiotic or trial drug-modifying AEs (p = 0.004), and 24 (6.5%) participants in the rifampicin group versus 6 (1.5%) participants in the placebo group experienced drug-interactions (p = 0.0005). Evaluation of the costs and health-related quality-of-life impacts revealed that an episode of S. aureus bacteraemia costs an average of £12,197 over 12 weeks. Rifampicin was estimated to save 10% of episode costs (p = 0.14). After adjustment, the effect of rifampicin on total quality-adjusted life-years (QALYs) was positive (0.004 QALYs), but not statistically significant (standard error 0.004 QALYs). CONCLUSIONS Adjunctive rifampicin provided no overall benefit over standard antibiotic therapy in adults with S. aureus bacteraemia. FUTURE WORK Given the substantial mortality, other antibiotic combinations or improved source management should be investigated. TRIAL REGISTRATIONS Current Controlled Trials ISRCTN37666216, EudraCT 2012-000344-10 and Clinical Trials Authorisation 00316/0243/001. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 59. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Guy E Thwaites
- Nuffield Department of Medicine, University of Oxford, Oxford, UK.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | - Alexander Szubert
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | | | - Marta Soares
- Centre for Health Economics, University of York, York, UK
| | - Jennifer Bostock
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Emmanuel Nsutebu
- Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Robert Tilley
- Department of Microbiology, Plymouth Hospitals NHS Trust, Plymouth, UK
| | | | - Julia Greig
- Department of Infectious Diseases, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Sarah A Wyllie
- Microbiology Department, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Peter Wilson
- Centre for Clinical Microbiology, University College London Hospital NHS Foundation Trust, London, UK
| | - Cressida Auckland
- Microbiology Department, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Janet Cairns
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Denise Ward
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Pankaj Lal
- Microbiology Department, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Achyut Guleri
- Microbiology Department, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - Neil Jenkins
- Department of Infectious Diseases and Tropical Medicine, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Julian Sutton
- Department of Microbiology and Virology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Martin Wiselka
- Department of Infection and Tropical Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - Clive Graham
- Microbiology Department, North Cumbria University Hospitals NHS Trust, Cumbria, UK
| | - Paul R Chadwick
- Microbiology Department, Salford Royal NHS Foundation Trust, Salford, UK
| | - Gavin Barlow
- Department of Infection, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | - N Claire Gordon
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Bernadette Young
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Sarah Meisner
- Microbiology Department, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Paul McWhinney
- Microbiology Department, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - David A Price
- Department of Infectious Diseases, Newcastle Upon Tyne Hospital NHS Foundation Trust, Newcastle, UK
| | - David Harvey
- Microbiology Department, Wirral University Teaching Hospital NHS Foundation Trust, Birkenhead, UK
| | - Deepa Nayar
- Microbiology Department, County Durham and Darlington NHS Foundation Trust, Durham, UK
| | - Dakshika Jeyaratnam
- Department of Microbiology, King's College Hospital NHS Foundation Trust, London, UK
| | - Timothy Planche
- Department of Infectious Diseases and Tropical Medicine, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Jane Minton
- Department of Infectious Diseases, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Fleur Hudson
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Susan Hopkins
- Infectious Diseases Unit, Royal Free London NHS Foundation Trust, London, UK
| | - John Williams
- Department of Infectious Diseases, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - M Estee Török
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Martin J Llewelyn
- Department of Infectious Diseases, Brighton and Sussex Medical School, Brighton, UK
| | - Jonathan D Edgeworth
- Department of Immunology, Infectious and Inflammatory diseases, King's College London, London, UK
| | - A Sarah Walker
- Nuffield Department of Medicine, University of Oxford, Oxford, UK.,Medical Research Council Clinical Trials Unit, University College London, London, UK
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Pouwels KB, Hopkins S, Llewelyn MJ, Walker AS, McNulty CA, Robotham JV. Duration of antibiotic treatment for common infections in English primary care: cross sectional analysis and comparison with guidelines. BMJ 2019; 364:l440. [PMID: 30814052 PMCID: PMC6391655 DOI: 10.1136/bmj.l440] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To evaluate the duration of prescriptions for antibiotic treatment for common infections in English primary care and to compare this with guideline recommendations. DESIGN Cross sectional study. SETTING General practices contributing to The Health Improvement Network database, 2013-15. PARTICIPANTS 931 015 consultations that resulted in an antibiotic prescription for one of several indications: acute sinusitis, acute sore throat, acute cough and bronchitis, pneumonia, acute exacerbation of chronic obstructive pulmonary disease (COPD), acute otitis media, acute cystitis, acute prostatitis, pyelonephritis, cellulitis, impetigo, scarlet fever, and gastroenteritis. MAIN OUTCOME MEASURES The main outcomes were the percentage of antibiotic prescriptions with a duration exceeding the guideline recommendation and the total number of days beyond the recommended duration for each indication. RESULTS The most common reasons for antibiotics being prescribed were acute cough and bronchitis (386 972, 41.6% of the included consultations), acute sore throat (239 231, 25.7%), acute otitis media (83 054, 8.9%), and acute sinusitis (76 683, 8.2%). Antibiotic treatments for upper respiratory tract indications and acute cough and bronchitis accounted for more than two thirds of the total prescriptions considered, and 80% or more of these treatment courses exceeded guideline recommendations. Notable exceptions were acute sinusitis, where only 9.6% (95% confidence interval 9.4% to 9.9%) of prescriptions exceeded seven days and acute sore throat where only 2.1% (2.0% to 2.1%) exceeded 10 days (recent guidance recommends five days). More than half of the antibiotic prescriptions were for longer than guidelines recommend for acute cystitis among females (54.6%, 54.1% to 55.0%). The percentage of antibiotic prescriptions exceeding the recommended duration was lower for most non-respiratory infections. For the 931 015 included consultations resulting in antibiotic prescriptions, about 1.3 million days were beyond the durations recommended by guidelines. CONCLUSION For most common infections treated in primary care, a substantial proportion of antibiotic prescriptions have durations exceeding those recommended in guidelines. Substantial reductions in antibiotic exposure can be accomplished by aligning antibiotic prescription durations with guidelines.
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Affiliation(s)
- Koen B Pouwels
- Modelling and Economics Unit, National Infection Service, Public Health England, London NW9 5EQ, UK
- Department of Health Sciences, Global Health, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Susan Hopkins
- Healthcare-Associated Infection and Antimicrobial Resistance Department, National Infection Service, Public Health England, London, UK
- Directorate of Infection, Royal Free London NHS Foundation Trust, London, UK
- National Institute for Health Research Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance, Oxford, UK
| | - Martin J Llewelyn
- Department of Global Health and Infection, Brighton and Sussex Medical School, Falmer, Brighton, UK
- Department of Microbiology and Infection, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Ann Sarah Walker
- National Institute for Health Research Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance, Oxford, UK
- Nuffield Department of Medicine, University of Oxford, UK
| | - Cliodna Am McNulty
- Public Health England Primary Care Unit, Microbiology Department, Gloucestershire Royal Hospital, Gloucester, UK
| | - Julie V Robotham
- Modelling and Economics Unit, National Infection Service, Public Health England, London NW9 5EQ, UK
- National Institute for Health Research Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance, Oxford, UK
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Schweitzer VA, van Heijl I, van Werkhoven CH, Islam J, Hendriks-Spoor KD, Bielicki J, Bonten MJM, Walker AS, Llewelyn MJ. The quality of studies evaluating antimicrobial stewardship interventions: a systematic review. Clin Microbiol Infect 2018; 25:555-561. [PMID: 30472426 DOI: 10.1016/j.cmi.2018.11.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 10/25/2018] [Accepted: 11/03/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Antimicrobial stewardship aims to optimize antibiotic use and minimize selection of antimicrobial resistance. The methodological quality of published studies in this field is unknown. AIMS Our objective was to perform a comprehensive systematic review of antimicrobial stewardship research design and identify features which limit validity and translation of research findings into clinical practice. SOURCES The following online database was searched: PubMed. STUDY ELIGIBILITY CRITERIA Studies published between January 1950 and January 2017, evaluating any antimicrobial stewardship intervention in the community or hospital setting, without restriction on study design or outcome. CONTENT We extracted data on pre-specified design quality features and factors that may influence design choices including (1) clinical setting, (2) age group studied, (3) when the study was conducted, (4) geographical region, and (5) financial support received. The initial search yielded 17 382 articles; 1008 were selected for full-text screening, of which 825 were included. Most studies (675/825, 82%) were non-experimental; 104 (15%) used interrupted time series analysis, 41 (6%) used external controls, and 19 (3%) used both. Studies in the community setting fulfilled a median of five out of 10 quality features (IQR 3-7) and 3 (IQR 2-4) in the hospital setting. Community setting studies (25%, 205/825) were significantly more likely to use randomization (OR 5.9; 95% CI 3.8-9.2), external controls (OR 5.6; 95% CI 3.6-8.5), and multiple centres (OR 10.5; 95% CI 7.1-15.7). From all studies, only 48% (398/825) reported clinical and 23% (190/825) reported microbiological outcomes. Quality did not improve over time. IMPLICATIONS Overall quality of antimicrobial stewardship studies is low and has not improved over time. Most studies do not report clinical and microbiological outcome data. Studies conducted in the community setting were associated with better quality. These limitations should inform the design of future stewardship evaluations so that a robust evidence base can be built to guide clinical practice.
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Affiliation(s)
- V A Schweitzer
- Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, The Netherlands.
| | - I van Heijl
- Department of Clinical Pharmacy and Medical Microbiology, Tergooi Hospital, Hilversum/Blaricum, The Netherlands
| | - C H van Werkhoven
- Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, The Netherlands
| | - J Islam
- Department of Global Health and Infection, Brighton and Sussex Medical School, Falmer, UK
| | - K D Hendriks-Spoor
- Department of Clinical Pharmacy and Medical Microbiology, Tergooi Hospital, Hilversum/Blaricum, The Netherlands
| | - J Bielicki
- Paediatric Infectious Disease Research Group, St George's University of London, London, UK
| | - M J M Bonten
- Department of Medical Microbiology, University Medical Center Utrecht, The Netherlands
| | - A S Walker
- MRC Clinical Trials Unit, University College London, London, UK
| | - M J Llewelyn
- Department of Global Health and Infection, Brighton and Sussex Medical School, Falmer, UK
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Price JR, Crook DW, Walker AS, Peto TEA, Llewelyn MJ, Paul J. Staphylococcus aureus in critical care - Authors' reply. Lancet Infect Dis 2018; 17:580-581. [PMID: 28555579 DOI: 10.1016/s1473-3099(17)30269-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 04/27/2017] [Indexed: 10/19/2022]
Affiliation(s)
- James R Price
- Department of Microbiology and Infection, Royal Sussex County Hospital, Brighton, UK.
| | - Derrick W Crook
- Nuffield Department of Clinical Medicine, Experimental Medicine Division, John Radcliffe Hospital, Oxford, UK; National Institute for Health Research Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK; Public Health England, London, UK
| | - A Sarah Walker
- Nuffield Department of Clinical Medicine, Experimental Medicine Division, John Radcliffe Hospital, Oxford, UK; National Institute for Health Research Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
| | - Timothy E A Peto
- Nuffield Department of Clinical Medicine, Experimental Medicine Division, John Radcliffe Hospital, Oxford, UK; National Institute for Health Research Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
| | - Martin J Llewelyn
- Department of Microbiology and Infection, Royal Sussex County Hospital, Brighton, UK; Division of Medicine, Brighton and Sussex Medical School, Falmer, UK
| | - John Paul
- Department of Microbiology and Infection, Royal Sussex County Hospital, Brighton, UK; Public Health England, Royal Sussex County Hospital, Brighton, UK
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Nambiar K, Seifert H, Rieg S, Kern WV, Scarborough M, Gordon NC, Kim HB, Song KH, Tilley R, Gott H, Liao CH, Edgeworth J, Nsutebu E, López-Cortés LE, Morata L, Walker AS, Thwaites G, Llewelyn MJ, Kaasch AJ. Survival following Staphylococcus aureus bloodstream infection: A prospective multinational cohort study assessing the impact of place of care. J Infect 2018; 77:516-525. [PMID: 30179645 DOI: 10.1016/j.jinf.2018.08.015] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 08/25/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Staphylococcus aureus bloodstream infection (SAB) is a common, life-threatening infection with a high mortality. Survival can be improved by implementing quality of care bundles in hospitals. We previously observed marked differences in mortality between hospitals and now assessed whether mortality could serve as a valid and easy to implement quality of care outcome measure. METHODS We conducted a prospective observational study between January 2013 and April 2015 on consecutive, adult patients with SAB from 11 tertiary care centers in Germany, South Korea, Spain, Taiwan, and the United Kingdom. Factors associated with mortality at 90 days were analyzed by Cox proportional hazards regression and flexible parametric models. RESULTS 1851 patients with a median age of 66 years (64% male) were analyzed. Crude 90-day mortality differed significantly between hospitals (range 23-39%). Significant variation between centers was observed for methicillin-resistant S. aureus, community-acquisition, infective foci, as well as measures of comorbidities, and severity of disease. In multivariable analysis, factors independently associated with mortality at 90 days were age, nosocomial acquisition, unknown infective focus, pneumonia, Charlson comorbidity index, SOFA score, and study center. The risk of death varied over time differently for each infective focus. Crude mortality differed markedly from adjusted mortality. DISCUSSION We observed significant differences in adjusted mortality between hospitals, suggesting differences in quality of care. However, mortality is strongly influenced by patient mix and thus, crude mortality is not a suitable quality indicator.
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Affiliation(s)
- Kate Nambiar
- Department of Microbiology and Infectious Diseases, Brighton and Sussex University Hospitals NHS Trust, Royal Sussex County Hospital, Eastern Road, Brighton, BN2 5BE, United Kingdom
| | - Harald Seifert
- Institute for Medical Microbiology, Immunology and Hygiene, Faculty of Medicine, University of Cologne, Goldenfelsstr. 19, 50935 Cologne, Germany; German Center for Infection Research (DZIF), partner site Bonn-Cologne, Germany
| | - Siegbert Rieg
- Division of Infectious Diseases, Department of Medicine II, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg 79106, Freiburg, Germany
| | - Winfried V Kern
- Division of Infectious Diseases, Department of Medicine II, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg 79106, Freiburg, Germany
| | - Matt Scarborough
- Nuffield Department of Medicine, Oxford University Hospitals NHS Foundation, Headington, Oxford, OX3 9DU, United Kingdom
| | - N Claire Gordon
- Nuffield Department of Medicine, Oxford University Hospitals NHS Foundation, Headington, Oxford, OX3 9DU, United Kingdom
| | - Hong Bin Kim
- Department of Internal Medicine, Seoul National University College of Medicine and Division of Infectious Diseases, Seoul National University Bundang Hospital, 173-82 Gumi-ro, Bundang-gu, Seongnam, Gyeonggi-do, 13620, Republic of Korea
| | - Kyoung-Ho Song
- Department of Internal Medicine, Seoul National University College of Medicine and Division of Infectious Diseases, Seoul National University Bundang Hospital, 173-82 Gumi-ro, Bundang-gu, Seongnam, Gyeonggi-do, 13620, Republic of Korea
| | - Robert Tilley
- Department of Microbiology, Plymouth Hospitals NHS Trust, Derriford Hospital, Derriford Road, Crownhill, Plymouth, PL6 8DH, United Kingdom
| | - Hannah Gott
- Department of Research and Development, Plymouth Hospitals NHS Trust, Derriford Hospital, Derriford Road, Crownhill, Plymouth, PL6 8DH, United Kingdom
| | - Chun-Hsing Liao
- Infectious Diseases, Department of Internal Medicine, Far Eastern Memorial Hospital, No. 21, Section 2, Nanya South Road, Banchio District, New Taipei City 220, Taiwan; Department of Medicine, Yang-Ming University, No. 155, Section 2, Linong Street, Taipei 112, Taiwan
| | - Jonathan Edgeworth
- Centre for Clinical Infection and Diagnostics Research, Department of Infectious Diseases, Kings College London, Guy's and St. Thomas' Hospitals NHS Foundation Trust, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, United Kingdom
| | - Emmanuel Nsutebu
- Tropical & Infectious Disease Unit, Royal Liverpool and Broadgreen University Teaching Hospital, Prescot Street, Liverpool, L7 8XP, United Kingdom
| | - Luis Eduardo López-Cortés
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena /CSIC / Instituto de Biomedicina de Sevilla (IBiS), Avda Dr Fedriani, s/n. 41003 Seville, Spain
| | - Laura Morata
- Service of Infectious Diseases, Hospital Clínic of Barcelona, Barcelona, Spain
| | - A Sarah Walker
- Medical Research Council Clinical Trials Unit at University College London, University College London, United Kingdom; Nuffield Department of Medicine, University of Oxford, Level 7 Microbiology, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, United Kingdom
| | - Guy Thwaites
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, United Kingdom
| | - Martin J Llewelyn
- Department of Microbiology and Infectious Diseases, Brighton and Sussex University Hospitals NHS Trust, Royal Sussex County Hospital, Eastern Road, Brighton, BN2 5BE, United Kingdom
| | - Achim J Kaasch
- Institute of Medical Microbiology and Hospital Hygiene, Faculty of Medicine, Heinrich-Heine-University Düsseldorf, Universitätsstraße 1, 40225 Düsseldorf, Germany.
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50
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Vihta KD, Stoesser N, Llewelyn MJ, Quan TP, Davies T, Fawcett NJ, Dunn L, Jeffery K, Butler CC, Hayward G, Andersson M, Morgan M, Oakley S, Mason A, Hopkins S, Wyllie DH, Crook DW, Wilcox MH, Johnson AP, Peto TEA, Walker AS. Trends over time in Escherichia coli bloodstream infections, urinary tract infections, and antibiotic susceptibilities in Oxfordshire, UK, 1998-2016: a study of electronic health records. Lancet Infect Dis 2018; 18:1138-1149. [PMID: 30126643 DOI: 10.1016/s1473-3099(18)30353-0] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 05/21/2018] [Accepted: 05/24/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Escherichia coli bloodstream infections are increasing in the UK and internationally. The evidence base to guide interventions against this major public health concern is small. We aimed to investigate possible drivers of changes in the incidence of E coli bloodstream infection and antibiotic susceptibilities in Oxfordshire, UK, over the past two decades, while stratifying for time since hospital exposure. METHODS In this observational study, we used all available data on E coli bloodstream infections and E coli urinary tract infections (UTIs) from one UK region (Oxfordshire) using anonymised linked microbiological data and hospital electronic health records from the Infections in Oxfordshire Research Database (IORD). We estimated the incidence of infections across a two decade period and the annual incidence rate ratio (aIRR) in 2016. We modelled the data using negative binomial regression on the basis of microbiological, clinical, and health-care-exposure risk factors. We investigated infection severity, 30-day all-cause mortality, and community and hospital amoxicillin plus clavulanic acid (co-amoxiclav) use to estimate changes in bacterial virulence and the effect of antimicrobial resistance on incidence. FINDINGS From Jan 1, 1998, to Dec 31, 2016, 5706 E coli bloodstream infections occurred in 5215 patients, and 228 376 E coli UTIs occurred in 137 075 patients. 1365 (24%) E coli bloodstream infections were nosocomial (onset >48 h after hospital admission), 1132 (20%) were quasi-nosocomial (≤30 days after discharge), 1346 (24%) were quasi-community (31-365 days after discharge), and 1863 (33%) were community (>365 days after hospital discharge). The overall incidence increased year on year (aIRR 1·06, 95% CI 1·05-1·06). In 2016, 212 (41%) of 515 E coli bloodstream infections and 3921 (28%) of 13 792 E coli UTIs were co-amoxiclav resistant. Increases in E coli bloodstream infections were driven by increases in community (aIRR 1·10, 95% CI 1·07-1·13; p<0·0001) and quasi-community (aIRR 1·08, 1·07-1·10; p<0·0001) cases. 30-day mortality associated with E coli bloodstream infection decreased over time in the nosocomial (adjusted rate ratio [RR] 0·98, 95% CI 0·96-1·00; p=0·03) group, and remained stable in the quasi-nosocomial (adjusted RR 0·98, 0·95-1·00; p=0·06), quasi-community (adjusted RR 0·99, 0·96-1·01; p=0·32), and community (adjusted RR 0·99, 0·96-1·01; p=0·21) groups. Mortality was, however, substantial at 14-25% across all hospital-exposure groups. Co-amoxiclav-resistant E coli bloodstream infections increased in all groups across the study period (by 11-18% per year, significantly faster than co-amoxiclav-susceptible E coli bloodstream infections; pheterogeneity<0·0001), as did co-amoxiclav-resistant E coli UTIs (by 14-29% per year; pheterogeneity<0·0001). Previous year co-amoxiclav use in primary-care facilities was associated with increased subsequent year community co-amoxiclav-resistant E coli UTIs (p=0·003). INTERPRETATION Increases in E coli bloodstream infections in Oxfordshire are primarily community associated, with substantial co-amoxiclav resistance; nevertheless, we found little or no change in mortality. Focusing interventions on primary care facilities, particularly those with high co-amoxiclav use, could be effective in reducing the incidence of co-amoxiclav-resistant E coli bloodstream infections, in this region and more generally. FUNDING National Institute for Health Research.
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Affiliation(s)
- Karina-Doris Vihta
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK; National Institute for Health Research (NIHR) Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance, Oxford, UK.
| | - Nicole Stoesser
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Martin J Llewelyn
- Brighton and Sussex Medical School, University of Sussex, Falmer, UK
| | - T Phuong Quan
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK; National Institute for Health Research (NIHR) Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance, Oxford, UK
| | - Tim Davies
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK; National Institute for Health Research (NIHR) Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance, Oxford, UK
| | - Nicola J Fawcett
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Laura Dunn
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Katie Jeffery
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Chris C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Gail Hayward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Marcus Morgan
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sarah Oakley
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Amy Mason
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Susan Hopkins
- National Infection Service, Public Health England, Colindale, UK
| | - David H Wyllie
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Derrick W Crook
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK; National Institute for Health Research (NIHR) Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance, Oxford, UK; National Infection Service, Public Health England, Colindale, UK
| | - Mark H Wilcox
- Healthcare Associated Infections Research Group, University of Leeds, Leeds, UK
| | - Alan P Johnson
- National Institute for Health Research (NIHR) Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance, Oxford, UK; National Infection Service, Public Health England, Colindale, UK
| | - Tim E A Peto
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK; National Institute for Health Research (NIHR) Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance, Oxford, UK
| | - A Sarah Walker
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK; National Institute for Health Research (NIHR) Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance, Oxford, UK
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