Evaluating the role of primary care pharmacy technicians in antimicrobial stewardship (AMS) and acne management using TARGET resources

Background

Inappropriate antibiotic prescribing is accelerating antimicrobial resistance (AMR) (Antibiotic resistant infections and associated deaths increase  https://www.gov.uk/government/news/antibiotic-resistant-infections-and-associated-deaths-increase). Pharmacy professionals (pharmacists and pharmacy technicians) promote good antibiotic prescribing practice. The traditional role of pharmacy technicians in supporting pharmacists and patients has expanded alongside the clinical expansion of pharmacist roles. (Boughen M, Fenn T. Practice, skill mix and education: the evolving role of pharmacy technicians in Great Britain. Pharmacy (Basel) 2020; 8(2): 50. doi:10.3390/pharmacy8020050) This paper focuses on the opinion of pharmacy technicians and their role in the review of acne management and the evaluation of the UKHSA TARGET acne 'How to…' review resources.

Aims and objectives

To explore the impact of the TARGET resources on the capability, opportunity and motivation of pharmacy technicians in general practice in managing patients with acne.To evaluate the usefulness of the acne 'How to…' review resources.

Materials and methods

A primarily quantitative study using an electronic survey asking UK-based pharmacy technicians to rate their agreement on a five-point Likert scale with 21 predefined statements, themed on the COM-B model and usefulness of the TARGET resources for acne.

Discussion

The survey found that capability and opportunity in managing acne in the group familiar with TARGET resources was higher than the group not familiar with TARGET resources. Scores for motivation in both groups were high; pharmacy technicians have the motivation to undertake infection management roles, whether or not they are familiar with the TARGET toolkit.The acne 'How to…' review resources were overall rated as useful in supporting the review of patients with acne.

Conclusion

The TARGET materials are effective resources that helps to upskill pharmacy technicians in the area of AMS, increasing capability and opportunity in the management of acne.

Clinical and health inequality risk factors for non-COVID-related sepsis during the global COVID-19 pandemic: a national case-control and cohort study

Background

Sepsis, characterised by significant morbidity and mortality, is intricately linked to socioeconomic disparities and pre-admission clinical histories. This study aspires to elucidate the association between non-COVID-19 related sepsis and health inequality risk factors amidst the pandemic in England, with a secondary focus on their association with 30-day sepsis mortality.

Methods

With the approval of NHS England, we harnessed the OpenSAFELY platform to execute a cohort study and a 1:6 matched case-control study. A sepsis diagnosis was identified from the incident hospital admissions record using ICD-10 codes. This encompassed 248,767 cases with non-COVID-19 sepsis from a cohort of 22.0 million individuals spanning January 1, 2019, to June 31, 2022. Socioeconomic deprivation was gauged using the Index of Multiple Deprivation score, reflecting indicators like income, employment, and education. Hospitalisation-related sepsis diagnoses were categorised as community-acquired or hospital-acquired. Cases were matched to controls who had no recorded diagnosis of sepsis, based on age (stepwise), sex, and calendar month. The eligibility criteria for controls were established primarily on the absence of a recorded sepsis diagnosis. Associations between potential predictors and odds of developing non-COVID-19 sepsis underwent assessment through conditional logistic regression models, with multivariable regression determining odds ratios (ORs) for 30-day mortality.

Findings

The study included 224,361 (10.2%) cases with non-COVID-19 sepsis and 1,346,166 matched controls. The most socioeconomic deprived quintile was associated with higher odds of developing non-COVID-19 sepsis than the least deprived quintile (crude OR 1.80 [95% CI 1.77-1.83]). Other risk factors (after adjusting comorbidities) such as learning disability (adjusted OR 3.53 [3.35-3.73]), chronic liver disease (adjusted OR 3.08 [2.97-3.19]), chronic kidney disease (stage 4: adjusted OR 2.62 [2.55-2.70], stage 5: adjusted OR 6.23 [5.81-6.69]), cancer, neurological disease, immunosuppressive conditions were also associated with developing non-COVID-19 sepsis. The incidence rate of non-COVID-19 sepsis decreased during the COVID-19 pandemic and rebounded to pre-pandemic levels (April 2021) after national lockdowns had been lifted. The 30-day mortality risk in cases with non-COVID-19 sepsis was higher for the most deprived quintile across all periods.

Interpretation

Socioeconomic deprivation, comorbidity and learning disabilities were associated with an increased odds of developing non-COVID-19 related sepsis and 30-day mortality in England. This study highlights the need to improve the prevention of sepsis, including more precise targeting of antimicrobials to higher-risk patients.

Funding

The UK Health Security Agency, Health Data Research UK, and National Institute for Health Research.

The impact of the COVID-19 pandemic on the treatment of common infections in primary care and the change to antibiotic prescribing in England

BACKGROUND

There is concern that the COVID-19 pandemic altered the management of common infections in primary care. This study aimed to evaluate infection-coded consultation rates and antibiotic use during the pandemic and how any change may have affected clinical outcomes.

METHODS

With the approval of NHS England, a retrospective cohort study using the OpenSAFELY platform analysed routinely collected electronic health data from GP practices in England between January 2019 and December 2021. Infection coded consultations and antibiotic prescriptions were used estimate multiple measures over calendar months, including age-sex adjusted prescribing rates, prescribing by infection and antibiotic type, infection consultation rates, coding quality and rate of same-day antibiotic prescribing for COVID-19 infections. Interrupted time series (ITS) estimated the effect of COVID-19 pandemic on infection-coded consultation rates. The impact of the pandemic on non- COVID-19 infection-related hospitalisations was also estimated.

RESULTS

Records from 24 million patients were included. The rate of infection-related consultations fell for all infections (mean reduction of 39% in 2020 compared to 2019 mean rate), except for UTI which remained stable. Modelling infection-related consultation rates highlighted this with an incidence rate ratio of 0.44 (95% CI 0.36-0.53) for incident consultations and 0.43 (95% CI 0.33-0.54) for prevalent consultations. Lower respiratory tract infections (LRTI) saw the largest reduction of 0.11 (95% CI 0.07-0.17). Antibiotic prescribing rates fell with a mean reduction of 118.4 items per 1000 patients in 2020, returning to pre-pandemic rates by summer 2021. Prescribing for LRTI decreased 20% and URTI increased 15.9%. Over 60% of antibiotics were issued without an associated same-day infection code, which increased during the pandemic. Infection-related hospitalisations reduced (by 62%), with the largest reduction observed for pneumonia infections (72.9%). Same-day antibiotic prescribing for COVID-19 infection increased from 1 to 10.5% between the second and third national lockdowns and rose again during 2022.

CONCLUSIONS

Changes to consultations and hospital admissions may be driven by reduced transmission of non-COVID-19 infections due to reduced social mixing and lockdowns. Inconsistencies in coding practice emphasises the need for improvement to inform new antibiotic stewardship policies and prevent resistance to novel infections.

Responding to Urinary Tract Infection Symptoms in England's Community Pharmacies

Most urinary tract infections (UTIs) are self-limiting and frequently present in primary care; it is common for patients to seek symptom relief. The TARGET Treating Your Infection (TYI) leaflet was used to respond to UTI symptoms for women under 65 years presenting in community pharmacies. The widespread use of these leaflets was incentivised as part of NHS England's Pharmacy Quality Scheme (PQS) 2022-23, between October 2022 and March 2023. The TARGET TYI leaflets are aimed to support appropriate antibiotic use and antimicrobial stewardship (AMS) as well as reducing the opportunity for resistance to develop. A total of 8363 community pharmacies completed the AMS criteria within the PQS and collectively submitted data for 104,142 patients presenting with UTI symptoms. The majority, 77% (75,071), of (non-pregnant) women presented with none or only one of the three strongly predictive symptoms of dysuria, new nocturia, cloudy urine, and/or vaginal discharge and, therefore, were less likely to have a UTI, as outlined in the English UTI diagnostic guidance. Conversely, 23% (22,381) of women presented with two or more symptoms of dysuria, new nocturia, cloudy urine, and with no vaginal discharge and, therefore, they were more likely to have a UTI. The TARGET TYI UTI leaflets support community pharmacy teams to differentiate between symptoms more likely to be associated with UTIs and those that could be managed with self-care. The findings suggest that most women presenting to community pharmacies with urinary symptoms were likely to have self-limiting symptoms, and could be suitably managed with self-care, pain relief, and appropriate safety netting. Approximately one-third of patients were managed by community pharmacy team members without the need for referral to a pharmacist and one in five patients presented with escalation symptoms and were signposted to other healthcare settings. A total of 94% (97,452) of women received self-care advice of which 36% (37,565) were also provided with additional patient information leaflets.

Repeated antibiotic exposure and risk of hospitalisation and death following COVID-19 infection (OpenSAFELY): a matched case-control study

Background

Identifying potential risk factors related to severe COVID-19 outcomes is important. Repeated intermittent antibiotic use is known be associated with adverse outcomes. This study aims to examine whether prior frequent antibiotic exposure is associated with severe COVID-19 outcomes.

Methods

With the approval of NHS England, we used the OpenSAFELY platform, which integrated primary and secondary care, COVID-19 test, and death registration data. This matched case-control study included 0.67 million patients (aged 18-110 years) from an eligible 2.47 million patients with incident COVID-19 by matching with replacement. Inclusion criteria included registration within one general practice for at least 3 years and infection with incident COVID-19. Cases were identified according to different severity of COVID-19 outcomes. Cases and eligible controls were 1:6 matched on age, sex, region of GP practice, and index year and month of COVID-19 infection. Five quintile groups, based on the number of previous 3-year antibiotic prescriptions, were created to indicate the frequency of prior antibiotic exposure. Conditional logistic regression used to compare the differences between case and control groups, adjusting for ethnicity, body mass index, comorbidities, vaccination history, deprivation, and care home status. Sensitivity analyses were done to explore potential confounding and the effects of missing data.

Findings

Based on our inclusion criteria, between February 1, 2020 and December 31, 2021, 98,420 patients were admitted to hospitals and 22,660 died. 55 unique antibiotics were prescribed. A dose-response relationship between number of antibiotic prescriptions and risk of severe COVID-19 outcome was observed. Patients in the highest quintile with history of prior antibiotic exposure had 1.80 times greater odds of hospitalisation compared to patients without antibiotic exposure (adjusted odds ratio [OR] 1.80, 95% Confidence Interval [CI] 1.75-1.84). Similarly, the adjusted OR for hospitalised patients with death outcomes was 1.34 (95% CI 1.28-1.41). Larger number of prior antibiotic type was also associated with more severe COVID-19 related hospital admission. The adjusted OR of quintile 5 exposure (the most frequent) with more than 3 antibiotic types was around 2 times larger than quintile 1 (only 1 type; OR 1.80, 95% CI 1.75-1.84 vs. OR 1.03, 95% CI 1.01-1.05).

Interpretation

Our observational study has provided evidence that antibiotic exposure frequency and diversity may be associated with COVID-19 severity, potentially suggesting adverse effects of repeated intermittent antibiotic use. Future work could work to elucidate causal links and potential mechanisms. Antibiotic stewardship should put more emphasis on long-term antibiotic exposure and its adverse outcome to increase the awareness of appropriate antibiotics use.

Funding

Health Data Research UK and National Institute for Health Research.

The impact of COVID-19 on antibiotic prescribing in primary care in England: Evaluation and risk prediction of appropriateness of type and repeat prescribing

BACKGROUND

This study aimed to predict risks of potentially inappropriate antibiotic type and repeat prescribing and assess changes during COVID-19.

METHODS

With the approval of NHS England, we used OpenSAFELY platform to access the TPP SystmOne electronic health record (EHR) system and selected patients prescribed antibiotics from 2019 to 2021. Multinomial logistic regression models predicted patient's probability of receiving inappropriate antibiotic type or repeat antibiotic course for each common infection.

RESULTS

The population included 9.1 million patients with 29.2 million antibiotic prescriptions. 29.1% of prescriptions were identified as repeat prescribing. Those with same day incident infection coded in the EHR had considerably lower rates of repeat prescribing (18.0%) and 8.6% had potentially inappropriate type. No major changes in the rates of repeat antibiotic prescribing during COVID-19 were found. In the 10 risk prediction models, good levels of calibration and moderate levels of discrimination were found.

CONCLUSIONS

Our study found no evidence of changes in level of inappropriate or repeat antibiotic prescribing after the start of COVID-19. Repeat antibiotic prescribing was frequent and varied according to regional and patient characteristics. There is a need for treatment guidelines to be developed around antibiotic failure and clinicians provided with individualised patient information.

Impact of COVID-19 on broad-spectrum antibiotic prescribing for common infections in primary care in England: a time-series analyses using OpenSAFELY and effects of predictors including deprivation

Background

The COVID-19 pandemic impacted the healthcare systems, adding extra pressure to reduce antimicrobial resistance. Therefore, we aimed to evaluate changes in antibiotic prescription patterns after COVID-19 started.

Methods

With the approval of NHS England, we used the OpenSAFELY platform to access the TPP SystmOne electronic health record (EHR) system in primary care and selected patients prescribed antibiotics from 2019 to 2021. To evaluate the impact of COVID-19 on broad-spectrum antibiotic prescribing, we evaluated prescribing rates and its predictors and used interrupted time series analysis by fitting binomial logistic regression models.

Findings

Over 32 million antibiotic prescriptions were extracted over the study period; 8.7% were broad-spectrum. The study showed increases in broad-spectrum antibiotic prescribing (odds ratio [OR] 1.37; 95% confidence interval [CI] 1.36-1.38) as an immediate impact of the pandemic, followed by a gradual recovery with a 1.1-1.2% decrease in odds of broad-spectrum prescription per month. The same pattern was found within subgroups defined by age, sex, region, ethnicity, and socioeconomic deprivation quintiles. More deprived patients were more likely to receive broad-spectrum antibiotics, which differences remained stable over time. The most significant increase in broad-spectrum prescribing was observed for lower respiratory tract infection (OR 2.33; 95% CI 2.1-2.50) and otitis media (OR 1.96; 95% CI 1.80-2.13).

Interpretation

An immediate reduction in antibiotic prescribing and an increase in the proportion of broad-spectrum antibiotic prescribing in primary care was observed. The trends recovered to pre-pandemic levels, but the consequence of the COVID-19 pandemic on AMR needs further investigation.

Funding

This work was supported by Health Data Research UK and by National Institute for Health Research.

The Use of the TARGET Antibiotic Checklist to Support Antimicrobial Stewardship in England's Community Pharmacies

Antimicrobial Stewardship (AMS) requires effective teamwork between healthcare professionals, with patients receiving consistent messages from all healthcare professionals on the appropriate antimicrobial use. Patient education may reduce patients' expectations to receive antibiotics for self-limiting conditions and reduce the pressure on primary care clinicians to prescribe antibiotics. The TARGET Antibiotic Checklist is part of the national AMS resources for primary care and aims to support interaction between community pharmacy teams and patients prescribed antibiotics. The Checklist, completed by the pharmacy staff with patients, invites patients to report on their infection, risk factors, allergies, and knowledge of antibiotics. The TARGET antibiotic checklist was part of the AMS criteria of England's Pharmacy Quality Scheme for patients presenting with an antibiotic prescription from September 2021 to May 2022. A total of 9950 community pharmacies claimed for the AMS criteria and 8374 of these collectively submitted data from 213,105 TARGET Antibiotic Checklists. In total, 69,861 patient information leaflets were provided to patients to aid in the knowledge about their condition and treatment. 62,544 (30%) checklists were completed for patients with an RTI; 43,093 (21%) for UTI; and 30,764 (15%) for tooth/dental infections. An additional 16,625 (8%) influenza vaccinations were delivered by community pharmacies prompted by discussions whilst using the antibiotic checklist. Community pharmacy teams promoted AMS using the TARGET Antibiotic Checklist, providing indication-specific education and positively impacting the uptake of influenza vaccinations.

Development of National Antimicrobial Intravenous-to-Oral Switch Criteria and Decision Aid

Introduction: Antimicrobial stewardship (AMS) strategies, such as intravenous-to-oral switch (IVOS), promote optimal antimicrobial use, contributing to safer and more effective patient care and tackling antimicrobial resistance (AMR). Aim: This study aimed to achieve nationwide multidisciplinary expert consensus on antimicrobial IVOS criteria for timely switch in hospitalised adult patients and to design an IVOS decision aid to operationalise agreed IVOS criteria in the hospital setting. Method: A four-step Delphi process was chosen to achieve expert consensus on IVOS criteria and decision aid; it included (Step One) Pilot/1st round questionnaire, (Step Two) Virtual meeting, (Step Three) 2nd round questionnaire and (Step 4) Workshop. This study follows the Appraisal of Guidelines for Research and Evaluation II instrument checklist. Results: The Step One questionnaire of 42 IVOS criteria had 24 respondents, 15 of whom participated in Step Two, in which 37 criteria were accepted for the next step. Step Three had 242 respondents (England n = 195, Northern Ireland n = 18, Scotland n = 18, Wales n = 11); 27 criteria were accepted. Step Four had 48 survey respondents and 33 workshop participants; consensus was achieved for 24 criteria and comments were received on a proposed IVOS decision aid. Research recommendations include the use of evidence-based standardised IVOS criteria. Discussion and Conclusion: This study achieved nationwide expert consensus on antimicrobial IVOS criteria for timely switch in the hospitalised adult population. For criteria operationalisation, an IVOS decision aid was developed. Further research is required to provide clinical validation of the consensus IVOS criteria and to expand this work into the paediatric and international settings.

Development of evidence-based UK-wide antimicrobial intravenous-to-oral switch criteria: a DELPHI consensus process

Introduction

Antimicrobial intravenous-to-oral switch (IVOS) is an antimicrobial stewardship (AMS) strategy with patient safety and cost-effectiveness benefits. Studies show that IVOS decisions had no negative impact on patient outcomes,1 and pharmacist involvement brought about more appropriate antibiotic prescribing and 34% reduction in medication costs.2 Healthcare settings have developed individualised local IVOS checklists.

Aim

To collate IVOS criteria from local checklists, complete a rapid literature review to evaluate IVOS criteria and undertake a 3-step Delphi consensus-gathering process to agree evidence-based, UK-wide IVOS criteria for hospitalised adults.

Methods

Local IVOS checklists from the UK nations were sought through stratified sampling. The rapid review followed PRISMA guidance and is registered on PROSPERO [CRD42022320343]. Criteria with highest, or over 50%, appearance in checklists and literature were combined for Step 1 of the 3-step Delphi process. Step 1: Pilot/1st round questionnaire: An expert panel appraised each criterion via a 5-point Likert scale for relevance to safe and effective IVOS and ease of assessment in the clinical setting. Step 2: Virtual meeting: Step 1 respondents discussed questionnaire results and attained criteria consensus for Step 3. Step 3: 2nd round questionnaire: Healthcare professionals UK-wide stated level of agreement via a 5-point Likert scale regarding the need of each criterion for safe and effective IVOS.

Results

Forty-five local IVOS checklists were selected: 42 from English Acute Trusts, two from Scottish Health Boards and the All-Wales checklist. Sixteen of 477 papers were included in the rapid review. Criteria were synthesised into a 5-section framework: 1-Timing of IV antimicrobial review; 2-Clinical signs and symptoms; 3-Infection markers; 4-Enteral route; 5-Infection exclusions. Combination of IVOS criteria resulted in 41 criteria for Step 1. Step 1 had 24 respondents, 15 of those participated in Step 2. Thirty-five criteria went into Step 3, which had 242 respondents (England n=195, Northern Ireland n=18, Scotland n=18, Wales n=11). The majority were female (n=154; n=7 preferred not to say) and based in NHS Acute Teaching Trusts (n=121). Antimicrobial or infection specialist pharmacists were the highest respondents (n=65) followed by general physicians (n=55). Sixty-seven per cent of respondents (n=161) considered IVOS to have a positive impact on outcomes of clinically stable patients. Consensus was achieved for 27 IVOS criteria (66% of initial criteria). Examples of agreed criteria were: ‘IVOS should be considered within 48 hours of first dose of IV antimicrobial being administered’ and ‘Temperature between 36-38°C for past 24 hours’.

Discussion/Conclusion

Evidence-based consensus was achieved for IVOS criteria from a UK-wide multidisciplinary group and will be used to develop an IVOS tool for hospitalised adults. A study strength was use of the Delphi process to capture consensus; a limitation was no checklist from Northern Ireland was identified at time of the study, however Steps 1-3 had participation from Northern Ireland. Early IVOS initiatives led by ward pharmacists have previously been shown to reduce use of hospital intravenous broad-spectrum antibiotics: co-amoxiclav (-27.9%) and cefuroxime (-46.5%).3 Further research is needed to operationalise the nationally agreed criteria in UK hospitals, expand AMS roles of pharmacy and nursing teams and assess impact.

References

1. Wongkamhla T, Khan-Asa B, Tongsai S, Angkasekwinai N. Infectious Disease Team Review Using Antibiotic Switch and Discharge Criteria Shortens the Duration of Intravenous Antibiotic: A Single-Center Cluster-Randomized Controlled Trial in Thailand. Open Forum Infect Dis. 2020;7(12):ofaa539.

2. Polidori P, Leonardi Vinci D, Adami S, Bianchi S, Faggiano ME, Provenzani A. Role of the hospital pharmacist in an Italian antimicrobial stewardship programme. Eur J Hosp Pharm. 2021;29:95-100.

3. Sze WT, Kong MC. Impact of printed antimicrobial stewardship recommendations on early intravenous to oral antibiotics switch practice in district hospitals. Pharm Pract. 2018;16(2):855.

Evaluating Ceftriaxone 80 mg/kg Administration by Rapid Intravenous Infusion-A Clinical Service Evaluation

In pediatric ambulatory care, the speed of medication infusion can have major impact on healthcare staff workload and the number of children able to be treated by services designed to reduce inpatient length of stay. In many regions of the world, local and supraregional guidelines allow ceftriaxone infusions of ≥50 mg/kg in infants and children up to 12 years of age to be given over 10 minutes. The generic European summary of product characteristics for ceftriaxone does not state a specific infusion time for this dose range, although 1 manufacturers' summary of product characteristics in the United Kingdom states a 30-minute minimum infusion time. We conducted a formal service evaluation of a change in practice at a large UK pediatric children's hospital and demonstrated the clinical feasibility, safety, and high parent satisfaction of 10-minute ceftriaxone infusions for prescribed doses ≥50 mg/kg. This approach can improve patient flow within hospital-based ambulatory services as well as by community nursing teams administering antibiotics at home.

Adaptation of the WHO Essential Medicines List for national antibiotic stewardship policy in England: being AWaRe

OBJECTIVES

Appropriate use of and access to antimicrobials are key priorities of global strategies to combat antimicrobial resistance (AMR). The WHO recently classified key antibiotics into three categories (AWaRe) to improve access (Access), monitor important antibiotics (Watch) and preserve effectiveness of 'last resort' antibiotics (Reserve). This classification was assessed for antibiotic stewardship and quality improvement in English hospitals.

METHODS

Using an expert elicitation exercise, antibiotics used in England but not included in the WHO AWaRe index were added to an appropriate category following a workshop consensus exercise with national experts. The methodology was tested using national antibiotic prescribing data and presented by primary and secondary care.

RESULTS

In 2016, 46/108 antibiotics included within the WHO AWaRe index were routinely used in England and an additional 25 antibiotics also commonly used in England were not included in the WHO AWaRe index. WHO AWaRe-excluded and -included antibiotics were reviewed and reclassified according to the England-adapted AWaRE index with the justification by experts for each addition or alteration. Applying the England-adapted AWaRe index, Access antibiotics accounted for the majority (60.9%) of prescribing, followed by Watch (37.9%) and Reserve (0.8%); 0.4% of antibiotics remained unclassified. There was unexplained 2-fold variation in prescribing between hospitals within each AWaRe category, highlighting the potential for quality improvement.

CONCLUSIONS

We have adapted the WHO AWaRe index to create a specific index for England. The AWaRe index provides high-level understanding of antibiotic prescribing. Subsequent to this process the England AWaRe index is now embedded into national antibiotic stewardship policy and incentivized quality improvement schemes.

Characterizing the attitudes and motivations of Ontario dairy producers toward udder health

Considerable research has focused on identifying risk factors for intramammary infections, yet mastitis remains a pervasive disease on dairy farms. Increasingly, researchers are appreciating the role of dairy producer mindset in determining management style and thus udder health status of the herd. The objective of this study was to explore the attitudes and motivations of Ontario dairy farmers toward udder health in herds with varying bulk milk somatic cell count (BMSCC). In December 2011, 5 focus groups were conducted across Ontario, Canada, with independent groups of dairy producers representing low, medium, and high BMSCC herds. Groups were established based on producer's weighted BMSCC levels as recorded over the summer of 2011. A semi-structured interview guide was followed to discuss topics relating to udder health. Thematic analysis was performed on the interview transcripts. Generally, producers noted management techniques (specifically culling infected cows and monitoring BMSCC), a perceived wealth of information on mastitis control, and a proactive whole-herd management approach engender the perception of control over mastitis. Producers in the low BMSCC group were confident in their level of knowledge and control of mastitis in their herds, whereas high BMSCC producers generally felt lower levels of control. Several areas were identified by producers that counteract this perception, contributing to perceived low levels of control over mastitis. Participants identified that at certain times they do not understand the cause of BMSCC on their farm. This attitude was especially prominent in the high BMSCC group. Other times, producers cited improper sample handling, seasonal issues, perceived milk culture shortcomings, and low herd size as factors that limited their control over mastitis in their herds. Though producers generally have high levels of self-efficacy beliefs when it comes to udder health management, the perception still exists that, under certain situations, mastitis is uncontrollable. This highlights the fact that educational and extension efforts need to focus on ensuring that producers employ proven mastitis diagnostic, prevention, and treatment practices in a systematic manner, with realistic expectations.

Antibiotic Review Kit for Hospitals (ARK-Hospital): study protocol for a stepped-wedge cluster-randomised controlled trial

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.

Terahertz: dictating the frequency of life. Do macromolecular vibrational modes impose thermal limitations on terrestrial life?

Conditions on exoplanets include elevated temperatures and pressures. The response of carbon-based biological macromolecules to such conditions is then relevant to the viability of life. The capacity of proteins and ribozymes to catalyse reactions or bind receptors, and nucleic acids to convey information, depends on them sampling different conformational states. These are determined by macromolecular vibrational states, or phonon modes, accessible using terahertz (THz: 10¹²Hz) absorption spectroscopy. THz spectra of biological macromolecules exhibit broad absorption at approximately 6 THz (equating to approx. 280 K) corresponding to dense transitions between phonon modes. There are also troughs at approximately 10 THz (approx. 500 K) implying diminishing numbers of available conformational states at higher temperatures; hence, fewer routes by which biochemical processes can be realized, as equilibrium is approached. Could this conformational bottleneck hinder the operation of biological macromolecules at higher temperatures? We suggest that the troughs at approximately 10 THz in absorbance spectra indicate that the hydrogen bonds, charge interactions and geometry of biological macromolecules associated with terrestrial life impose fundamental vibrational properties that could limit the upper temperature at which they may function.

The effect of a single early high-dose vitamin D supplement on fracture union in patients with hypovitaminosis D: a prospective randomised trial

AIMS

To evaluate the effect of a single early high-dose vitamin D supplement on fracture union in patients with hypovitaminosis D and a long bone fracture.

PATIENTS AND METHODS

Between July 2011 and August 2013, 113 adults with a long bone fracture were enrolled in a prospective randomised double-blind placebo-controlled trial. Their serum vitamin D levels were measured and a total of 100 patients were found to be vitamin D deficient (< 20 ng/ml) or insufficient (< 30 ng/mL). These were then randomised to receive a single dose of vitamin D₃ orally (100 000 IU) within two weeks of injury (treatment group, n = 50) or a placebo (control group, n = 50). We recorded patient demographics, fracture location and treatment, vitamin D level, time to fracture union and complications, including vitamin D toxicity. Outcomes included union, nonunion or complication requiring an early, unplanned secondary procedure. Patients without an outcome at 15 months and no scheduled follow-up were considered lost to follow-up. The t-test and cross tabulations verified the adequacy of randomisation. An intention-to-treat analysis was carried out.

RESULTS

In all, 100 (89%) patients had hypovitaminosis D. Both treatment and control groups had similar demographics and injury characteristics. The initial median vitamin D levels were 16 ng/mL (interquartile range 5 to 28) in both groups (p = 0.885). A total of 14 patients were lost to follow-up (seven from each group), two had fixation failure (one in each group) and one control group patient developed an infection. Overall, the nonunion rate was 4% (two per group). No patient showed signs of clinical toxicity from their supplement.

CONCLUSIONS

Despite finding a high level of hypovitaminosis D, the rate of union was high and independent of supplementation with vitamin D₃. Cite this article: Bone Joint J 2017;99-B:1520-5.

Network, cluster and risk factor analyses for porcine reproductive and respiratory syndrome using data from swine sites participating in a disease control program

The objectives of this study were to describe networks of Ontario swine sites and their service providers (including trucking, feed, semen, gilt and boar companies); to categorize swine sites into clusters based on site-level centrality measures, and to investigate risk factors for porcine reproductive and respiratory syndrome (PRRS) using information gathered from the above-mentioned analyses. All 816 sites included in the current study were enrolled in the PRRS area regional control and elimination projects in Ontario. Demographics, biosecurity and network data were collected using a standardized questionnaire and PRRS status was determined on the basis of available diagnostic tests and assessment by site veterinarians. Two-mode networks were transformed into one-mode dichotomized networks. Cluster and risk factor analyses were conducted separately for breeding and growing pig sites. In addition to the clusters obtained from cluster analyses, other explanatory variables of interest included: production type, type of animal flow, use of a shower facility, and number of neighboring swine sites within 3km. Unadjusted univariable analyses were followed by two types of adjusted models (adjusted for production systems): a generalizing estimation equation model (GEE) and a generalized linear mixed model (GLMM). Results showed that the gilt network was the most fragmented network, followed by the boar and truck networks. Considering all networks simultaneously, approximately 94% of all swine sites were indirectly connected. Unadjusted risk factor analyses showed significant associations between almost all predictors of interest and PRRS positivity, but these disappeared once production system was taken into consideration. Finally, the vast majority of the variation on PRRS status was explained by production system according to GLMM, which shows the highly correlated nature of the data, and raises the point that interventions at this level could potentially have high impact in PRRS status change and/or maintenance.

Exploring the characteristics and dynamics of Ontario dairy herds experiencing increases in bulk milk somatic cell count during the summer

Regionally aggregated bulk milk somatic cell count (BMSCC) data from around the world shows a repeatable cyclicity, with the highest levels experienced during warm, humid seasons. No studies have evaluated this seasonal phenomenon at the herd level. The objectives of this study were to define summer seasonality in BMSCC on an individual herd basis, and subsequently to describe the characteristics and dynamics of herds with increased BMSCC in the summer. The data used for this analysis were from all dairy farms in Ontario, Canada, between January 2000 and December 2011 (n≈4,000 to 6,000 herds/yr). Bulk milk data were obtained from the milk marketing board and consisted of bulk milk production, components (fat, protein, lactose, other solids), and quality (BMSCC, bacterial count, inhibitor presence, freezing point), total milk quota of the farm, and milk quota and incentive fill percentage. A time-series linear mixed model, with random slopes and intercepts, was constructed using sine and cosine terms as predictors to describe seasonality, with herd as a random effect. For each herd, seasonality was described with reference to 1 cosine function of variable amplitude and phase shift. The predicted months of maximal and minimal BMSCC were then calculated. Herds were assigned as low, medium, and high summer increase (LSI, MSI, and HSI, respectively) based on percentiles of amplitude in BMSCC change for each of the 4 seasons. Using these seasonality classifications, 2 transitional repeated measures logistic regression models were built to assess the characteristics of MSI and HSI herds, using LSI herds as controls. Based on the analyses performed, a history of summer BMSCC increases increased the odds of experiencing a subsequent increase. As herd size decreased, the odds of experiencing HSI to MSI in BMSCC increased. Herds with more variability in daily BMSCC were at higher odds of experiencing MSI and HSI in BMSCC, as were herds with lower annual mean BMSCC. Finally, a negative association was noted between filling herd production targets and experiencing MSI to HSI in BMSCC. These findings provide farm advisors direction for predicting herds likely to experience increases in SCC over the summer, allowing them to proactively focus udder health prevention strategies before the high-risk summer period.

Investigation of the Occurrence of Porcine Reproductive and Respiratory Virus in Swine Herds Participating in an Area Regional Control and Elimination Project in Ontario, Canada

The main goal of this study was to investigate the occurrence of porcine reproductive and respiratory syndrome virus (PRRSV)-specific genotypes in swine sites in Ontario (Canada) using molecular, spatial and network data from a porcine reproductive and respiratory syndrome (PRRS) regional control project. For each site, location, animal movement service provider (truck companies), PRRSV status and sequencing data of the open reading frame 5 (ORF5) were obtained. Three-kilometre buffers were created to evaluate neighbourhood characteristics for each site. Social network analysis was conducted on swine sites and trucking companies to assemble the network and define network components. Three different PRRSV genotypes were used as outcomes for statistical analysis based on the region's phylogenetic tree of the ORF5. Multivariable exact logistic regression was conducted to investigate the association between being positive for a specific genotype and two main exposures of interest: (i) having at least one neighbour within three km also positive for the same genotype outside the production system and (ii) having at least one positive site for the same genotype in the same truck network component outside the production system. Results showed that the importance of area spread and truck network on PRRSV occurrence differed according to genotype. Additionally, the Ontario PRRS database appears suitable for conducting regional disease investigations. Finally, the use of relatively new tools available for network, spatial and molecular analysis could be useful in investigation, control and prevention of endemic infectious diseases in animal populations.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Antibiotic policies in acute English NHS trusts: implementation of 'Start Smart-Then Focus' and relationship with Clostridium difficile infection rates

OBJECTIVES

The objective of this study was to establish how antibiotic prescribing policies at National Health Service (NHS) hospitals match the England Department of Health 'Start Smart-Then Focus' recommendations and relate to Clostridium difficile infection (CDI) rates.

METHODS

Antibiotic pharmacists were surveyed regarding recommendations for empirical treatment of common syndromes ('Start Smart') and antimicrobial prescription reviews ('Focus') at their hospital trusts. If no response was provided, policy data were sought from trust websites and the MicroGuide app (Horizon Strategic Partners, UK). Empirical treatment recommendations were categorized as broad spectrum (a β-lactam penicillin/β-lactamase inhibitor, cephalosporin, quinolone or carbapenem) or narrow spectrum. CDI rates were gathered from the national mandatory surveillance system.

RESULTS

Data were obtained for 105/145 English acute hospital trusts (72%). β-Lactam/β-lactamase inhibitor combinations were recommended extensively. Only for severe community-acquired pneumonia and pyelonephritis were narrow-spectrum agents recommended first line at a substantial number of trusts [42/105 (40%) and 50/105 (48%), respectively]. Policies commonly recommended dual therapy with aminoglycosides and β-lactams for abdominal sepsis [40/93 trusts (43%)] and undifferentiated severe sepsis [54/94 trusts (57%)]. Most policies recommended treating for ≥ 7 days for most indications. Nearly all policies [100/105 trusts (95%)] recommended antimicrobial prescription reviews, but only 46/96 respondents (48%) reported monitoring compliance. Independent predictors of higher CDI rates were recommending a broad-spectrum regimen for community-acquired pneumonia (P=0.06) and, counterintuitively, a recommended treatment duration of <48 h for nosocomial pneumonia (P=0.01).

CONCLUSIONS

Hospital antibiotic policies in the NHS 'Start Smart' by recommending broad-spectrum antibiotics for empirical therapy, but this may have the unintended potential to increase the use of broad-spectrum antibiotics and risk of CDI unless better mechanisms are in place to improve 'Focus'.

Complicated urinary tract infections: practical solutions for the treatment of multiresistant Gram-negative bacteria

Resistance in Gram-negative bacteria has been increasing, particularly over the last 6 years. This is mainly due to the spread of strains producing extended-spectrum β-lactamases (ESBLs) such as CTX-M enzymes or AmpC β-lactamases. Many of the isolates producing these enzymes are also resistant to trimethoprim, quinolones and aminoglycosides, often due to plasmid co-expression of other resistance mechanisms. CTX-M-producing Escherichia coli often occurs in the community and as E. coli is one of the commonest organisms causing urinary tract infections (UTIs) the choice of agents to treat these infections is diminishing. Novel combinations of antibiotics are being used in the community and broad-spectrum agents such as carbapenems are being used increasingly as empirical treatment for severe infections. Of particular concern therefore are reports in the UK of organisms that produce carbapenemases. As resistance is becoming more widespread, prudent use of antimicrobials is imperative and, as asymptomatic bacteriuria is typically benign in the elderly, antibiotics should not be prescribed without clinical signs of UTI. The use of antibiotics as suppressive therapy or long-term prophylaxis may no longer be defensible.

Genetic parameters of milking frequency and milk production traits in Canadian Holsteins milked by an automated milking system

Twice-a-day milking is currently the most frequently used milking schedule in Canadian dairy cattle. However, with an automated milking system (AMS), dairy cows can be milked more frequently. The objective of this study was to estimate genetic parameters for milking frequency and for production traits of cows milked within an AMS. Data were 141,927 daily records of 953 primiparous Holstein cows from 14 farms in Ontario and Quebec. Most cows visited the AMS 2 (46%) or 3 (37%) times a day. A 2-trait [daily (24-h) milking frequency and daily (24-h) milk yield] random regression daily animal model and a multiple-trait (milk, fat, protein yields, somatic cell score, and milking frequency) random regression test-day animal model were used for the estimation of (co)variance components. Both models included fixed effect of herd x test-date, fixed regressions on days in milk (DIM) nested within age at calving by season of calving, and random regressions for additive genetic and permanent environmental effects. Both fixed and random regressions were fitted with fourth-order Legendre polynomials on DIM. The number of cows in the multiple-trait test-day model was smaller compared with the daily animal model. Heritabilities from the daily model for daily (24-h) milking frequency and daily (24-h) milk yield ranged between 0.02 and 0.08 and 0.14 and 0.20, respectively. Genetic correlations between daily (24-h) milk yield and daily (24-h) milking frequency were largest at the end of lactation (0.80) and smallest in mid-lactation (0.27). Heritabilities from the test-day model for test-day milking frequency, milk, fat and protein yield, and somatic cell score were 0.14, 0.26, 0.20, 0.21, and 0.20, respectively. The genetic correlation was positive between test-day milking frequency and official test-day milk, fat, and protein yields, and negative between official test-day somatic cell score and test-day milking frequency.

Antibiotic pharmacists in the ascendancy

Specialist pharmacists have become an established feature of the antibiotic stewardship landscape in hospitals throughout the UK over the last decade. This review examines the origins of the specialist antibiotic pharmacist and how the role has developed in recent years. Antibiotic pharmacists fulfil a vital function in modern National Health Service hospitals as key members of the infection control team with overall responsibility for initiatives to promote rational antibiotic prescribing. Evidence of the impact of antibiotic pharmacists on clinical, microbiological and financial outcomes is presented along with examples of innovative practice. Finally, a vision for the future of the antibiotic pharmacist role is outlined.

Improving practice working together to improve the use of antimicrobials

The Hospital Pharmacy Initiative was a Department of Health funded programme in England between 2003 and 2006. It has produced a number of benefits that are organizational, educational, professional, clinical and economic. The opportunity to share experiences, identify what works well and collaborate across national boundaries to address a problem that is taxing all governments and NHS acute trusts and causes considerable concern to patients and their families should be a common goal for the UK.

Cervical screening history in patients with early stage carcinoma of the cervix

This study aimed to examine whether a decade of heightened publicity on issues relating to cervical screening has changed the screening profile of women presenting with cervical cancer at the National Maternity Hospital. The screening history of 100 women diagnosed with early/surgically treated cervical cancer between 1998 and 2002 was compared with a similar study conducted in 1982 /1990. The percentage of women never screened was similar - 24 %( 2002) and 23% (1990). The interval between last recorded smear and diagnosis of disease was greater than 5 years in 45.6% and 41.7% respectively. Overall 60% of women in the recent period had either failed to avail of screening or were not screened within 5 years of diagnosis compared with 64% in 1990. Multiparous women comprised 90% of the study group and 50% of those inadequately screened were attending their general practitioner on a regular basis - therefore affording a potential for opportunistic screening The current method of screening has failed in this group and has not improved in 10 years despite of increased population awareness and greater opportunities for screening than ever before and would support an argument for a National Screening Program.

Delayed leech-borne infection with Aeromonas hydrophilia in escharotic flap wound

Medicinal leeches (Hirudo medicinalis) are commonly used in plastic surgery for the salvage of congested flaps and replanted parts compromised by venous congestion. Infection associated with leech therapy is a documented complication of leech application, with reported incidences ranging from 2.4 to 20% [De Chalain TM. Exploring the use of the medicinal leech: a clinical risk-benefit analysis. J Reconstr Microsurg 1996;12(3):165-72.1]. We describe a case of delayed leech-borne infection, from the escharotic portion of a latissimus dorsi flap, which developed several days after stopping leech therapy for venous congestion in a reconstructed breast.

Prediction of the potentially fertile period by urinary hormone measurements using a new home-use monitor: comparison with laboratory hormone analyses

BACKGROUND

The study compared a new urinary hormone monitoring system, Clearview Primera Fertility Monitor (CPFM), with laboratory hormone analyses in the prediction of the potentially fertile period.

METHODS

Thirty healthy female volunteers provided blood and early morning urine samples for one cycle. Serum oestradiol, progesterone and luteinizing hormone (LH), and urinary LH and oestrone-3-glucuronide (E3G) were measured. The fertility status of volunteers; Low, High or Peak, was collected from monitors and compared with the hormone measurements.

RESULTS

There was agreement between the first day of peak fertility and the urinary LH peak day in 65.6% of cycles and detection 1 or 2 days before the urinary LH peak day in 24.1 and 6.9% of cycles respectively. In 58.6% of cycles the system detected up to 5 days of increased fertility prior to the urinary LH peak day. Warning days of the urinary LH peak were similarly determined using defined thresholds of E3G and oestradiol providing up to 5 days warning in 82.8 and 96.6% of cycles respectively.

CONCLUSIONS

The system can provide couples attempting to conceive with information about the potentially fertile days in the cycle in order that they may time intercourse. It also has potential for use in evaluation and treatment of infertile couples.

Kinetic and equilibrium characterization of vesamicol receptor-ligand complexes with picomolar dissociation constants

Previous studies from this laboratory characterized 83 analogs of vesamicol by their potencies for inhibition of acetylcholine active transport by synaptic vesicles isolated from Torpedo electric organ. Examination of the more potent of these compounds, plus five new analogs, by kinetic and equilibrium measurements on complexes with the vesamicol receptor (VR) revealed nine analogs that are significantly more potent than vesamicol. Equilibrium measurements were performed at very low protein concentrations and extended incubation times, which allowed the characterization of very high affinity analogs. Better understanding of the structural binding requirements of the VR has resulted, and a spatial map of allowed hydrophobicity has been clearly established. Three analogs were resolved, and they displayed enantioselectivity ratios as high as 260 for binding to the VR (10-times higher than that of vesamicol). The most potent analog, 4-aminobenzovesamicol (ABV), was synthesized in tritiated form and shown to dissociate from the VR with a half-life of about 14 hr at 20 degrees. The estimated dissociation constant is < or = 6.5 +/- 0.5 pM. By reciprocal kinetic experiments with vesamicol and ABV, coincidence of the two binding sites on vesicles was established. The high affinity and enantioselectivity of ABV and other similar analogs, coupled with good chemical and radiochemical stability, make these ligands attractive for the study of the VR in complex tissues. The observed difference between the equilibrium dissociation constant for the vesamicol-VR complex as estimated by titration with [3H]vesamicol (7.6 nM) and by displacement of subsaturating [3H]vesamicol by nonlabeled vesamicol (1.0 nM) suggests that high and low affinity populations of the VR exist.

Pharmacological profile of the substituted beta-lactam L-659,286: a member of a new class of human PMN elastase inhibitors

Human polymorphonuclear leukocyte elastase (PMN elastase) is inhibited by L-659,286 (7 alpha-methoxy-8-oxo-3-[[(1,2,5,6-tetrahydro-2-methyl-5,6-dioxo-1,2,4- triaz-in-3-yl)thio]methyl]-5-thia-1-aza-6R-bicyclo[4.2.O]oct-2-ene -2- pyrrolidine carboxamide-5,-dioxide) with a Ki of 0.4 microM. This inhibition is time-dependent, rapid, and only slowly reversible, with a t1/2 of greater than 3 days at 25 degrees C. L-659,286 is also highly selective for PMN elastase, as it does not inhibit thrombin, trypsin, papain, plasmin, chymotrypsin, or cathepsin G. L-659,286 administered intratracheally inhibits lung damage caused by administration via the same route of human PMN elastase into hamsters. In marmosets, L-659,286 is cleared from blood very rapidly after an intravenous injection but is recovered in bronchoalveolar lavage fluid for several hours after intratracheal administration.