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Objective: To develop a theory-informed behaviour change intervention to promote appropriate hospital antibiotic use, guided by the Medical Research Council's complex interventions framework. Methods: A phased approach was used, including triangulation of data from meta-ethnography and two qualitative studies. Central to intervention design was the generation of a robust theoretical basis using the Behaviour Change Wheel to identify relevant determinants of behaviour change and intervention components. Intervention content was guided by APEASE (Acceptability, Practicability, Effectiveness, Affordability, Side-effects, and Equity) criteria and coded using a Behaviour Change Technique Taxonomy. Stakeholders were involved throughout. Results: From numerous modifiable prescribing behaviours identified, active 'antibiotic time-out' was selected as the target behaviour to help clinicians safely initiate antibiotic reassessment. Prescribers' capability, opportunity, and motivation were potential drivers for changing this behaviour. The design process resulted in the selection of 25 behaviour change techniques subsequently translated into intervention content. Integral to this work was the development and refinement of a Digital Antibiotic Review Tracking Toolkit. Conclusion: This novel work demonstrates how the Behaviour Change Wheel can be used with the Medical Research Council framework to develop a theory-based behaviour change intervention targeting barriers to timely hospital antibiotic reassessment. Future research will evaluate the Antibiotic Toolkit's feasibility and effectiveness. [ABSTRACT FROM AUTHOR]

Antimicrobial resistance (AMR) is subject to extensive risk reduction approaches. A central strategy is reducing the unnecessary use of antimicrobials across agriculture and human and animal health care without jeopardising health outcomes for all species concerned. A prominent framework is antimicrobial stewardship which seeks to balance access to effective infection treatments with ensuring that effective antimicrobials are available for future generations. Balancing these goals has proven challenging and the consumption of antimicrobials and AMR both continue to grow. To shed light on this situation, we examined the risk reasoning that underpins AMR reduction in interviews with 51 practitioners, scientists and policy-makers working on AMR in Australia and the UK. Important themes in our analysis were that action to reduce infection risks clashed with AMR reduction rationalities. Participants were often not able to explain how treating an infection for an individual patient could harmonise with the longer-term goal of AMR reduction. Due to the potential for patient harm, making decisions to use antimicrobials was narrated as individualised and moralised. We argue that more effective AMR reduction depends on addressing this fundamental tension in AMR risk, and its individualising and moralising effects, as the starting point – not the outcome – of policy and practice for AMR reduction. [ABSTRACT FROM AUTHOR]

Background Patients with hematological malignancy are at high risk of invasive fungal infections (IFIs). Diagnosis is challenging, which can lead to overtreatment. Reducing exposure to inappropriate antifungal prescribing is likely to improve patient safety, but modifying prescribing behavior is difficult. We aimed to describe patterns and drivers of therapeutic antifungal prescribing in a large tertiary hemato-oncology center in the United Kingdom. Methods We studied adults receiving treatment for acute leukemia at our center between 1 April 2019 and 14 October 2022. We developed a reproducible method to analyze routinely collected data on antifungal therapy episodes in a widely used electronic health record system. We report antifungal use in days of therapy stratified by level of diagnostic confidence, as defined by consensus diagnostic guidelines (European Organisation for Research and Treatment of Cancer/Mycoses Study Group). Results Two hundred ninety-eight patients were included in the analysis; 21.7% of inpatient antifungal use occurred in cases of proven/probable IFI. Substantial antifungal use occurred in the absence of strong evidence of infection in patients receiving high-intensity first-line chemotherapy or approaching death (81.0% and 77.9%, respectively). Approximately 33% of high-resolution computed tomography (HRCT) reports were indeterminate for IFI. Indeterminate reports were around 8 times more likely to be followed by a new antifungal therapy episode than a negative report. Conclusions Antifungal stewardship remains challenging in the absence of reliable diagnostics, particularly in more unwell patients. The proportion of antifungal therapy given for proven/probable infection is a new metric that will likely be useful to target antifungal stewardship programs. The thoracic HRCT report is an important contributor to diagnostic uncertainty. [ABSTRACT FROM AUTHOR]

Antimicrobial resistance (AMR) is an urgent, global threat to public health. The development and implementation of effective measures to address AMR is vitally important but presents important ethical questions. This is a policy area requiring further sustained attention to ensure that policies proposed in National Action Plans on AMR are ethically acceptable and preferable to alternatives that might be fairer or more effective, for instance. By ethically analysing case studies of coercive actions to address AMR across countries, we can better inform policy in a context‐specific manner. In this article, I consider an example of coercive antimicrobial stewardship policy in Canada, namely restrictions on livestock farmers' access to certain antibiotics for animal use without a vet's prescription. I introduce and analyse two ethical arguments that might plausibly justify coercive action in this case: the harm principle and a duty of collective easy rescue. In addition, I consider the factors that might generally limit the application of those ethical concepts, such as challenges in establishing causation or evidencing the scale of the harm to be averted. I also consider specifics of the Canadian context in contrast to the UK and Botswana as example settings, to demonstrate how context‐specific factors might mean a coercive policy that is ethically justified in one country is not so in another. [ABSTRACT FROM AUTHOR]

Background: Measuring antimicrobial use is a core component of antimicrobial stewardship. Purchasing data may be easier to obtain than prescription data in some situations, but differences in clinic size, caseload and collection timeframes must be considered. Objective: Our objective was to evaluate purchases of systemic antibacterial agents by small animal veterinary facilities in 5 networks across 3 countries, using a mg/veterinarian full time equivalent (FTE)/week as the metric. Methods: Data were obtained from purchasing records of 2194 veterinary facilities from networks from the United States (US, n = 3: US‐A, 1036 facilities; US‐B, 101 facilities; US‐C, 886 facilities), Canada (n = 1: 117 facilities) and the United Kingdom (UK, n = 1: 54 facilities) during 2019‐2021. Results: In total, 20 020 269 767 mg (20.02 t) of antimicrobials were purchased. Overall differences between the UK and North America were driven by significantly higher purchases of amoxicillin‐clavulanic acid in the UK (P <.001), with substantially less purchasing of third generation cephalosporins in the UK (P <.0001). A significant association was found between FTE and purchasing, with decreased purchasing (mg/FTE/week) as facility FTE increased. Significant differences also were found among US regions. Facilities in the top 10% of total purchasing accounted for 23%‐30% of purchases, compared to only 1.6%‐3.8% for the bottom 10%. Conclusions and Clinical Importance: These data provide useful information about general purchasing trends, inter‐ and intraregional differences and differences among facility types and identify high purchasing outliers for further investigation. [ABSTRACT FROM AUTHOR]

As antimicrobial resistance (AMR) escalates globally, examining antibiotic treatment durations for respiratory infections becomes increasingly pertinent, especially in the context of the COVID-19 pandemic. In a UK secondary care setting, this retrospective study was carried out to assess the appropriateness of antibiotic treatment durations—shorter (≤5 days) versus longer (6–7 days and >8 days)—for respiratory tract infections (RTIs) in 640 adults across 2019 and 2020, in accordance with local antimicrobial guidelines. The analysis employed these guidelines and clinical evidence to examine the effectiveness and suitability of antibiotic prescribing practices. This study considered the 'Shorter Is Better' approach, noting an increased rate of patient discharges associated with shorter antibiotic regimens (≤5 days). It further demonstrates that shorter treatments are as effective as longer ones for conditions such as COPD exacerbation, COVID-19 pneumonia, and hospital-acquired pneumonia (HAP), except in cases of community-acquired pneumonia (CAP) and unspecified diagnoses. Nevertheless, this study raises concerns over an observed increase in mortality risk with shorter treatment durations. Although these mortality differences were not statistically significant and might have been influenced by the COVID-19 pandemic, the need for extended research with a larger sample size is highlighted to confirm these findings. This study also emphasises the critical need for accurate and specific diagnoses and considering risk assessments at admission, advocating for tailored, evidence-based antibiotic prescribing to ensure patient safety. It contributes to antimicrobial stewardship efforts by reinforcing the importance of adapting antibiotic use to current healthcare challenges and promoting a global commitment to fight antimicrobial resistance. This approach is crucial for enhancing patient outcomes and saving lives on a global scale. [ABSTRACT FROM AUTHOR]

Background: Threats such as African swine fever (ASF) are in close proximity to the UK; therefore, it is a crucial time to protect the British pig herd from exotic notifiable disease, which can be best achieved through legislative adherence. This is especially the case for laws around the feeding of pigs, which remains the likely route for ASF to enter the UK. Keepers of pigs on a small scale, including keepers of pet pigs, may show variable adherence to the relevant legislation. Furthermore, general farm practitioners, often responsible for supervising small‐scale pig holdings, may be less familiar with legislative requirements than those vets who deal solely with pigs. Despite this, legal requirements must be met on all holdings and overseeing vets are key to encouraging legislative compliance among keepers. Aim of the article: This article, the first in a two‐part series on working with small‐scale pig keepers, serves as a reference for vets so that they can provide their clients with up‐to‐date advice on how to keep pigs within the legal framework for the UK. It also offers advice on how this information could be shared among pig keepers. Part two, which will be published in a subsequent issue of In Practice, will focus on how we, as vets, can encourage antibiotic stewardship on smallholdings. [ABSTRACT FROM AUTHOR]

Background Molecular diagnostic tests may improve antibiotic prescribing by enabling earlier tailoring of antimicrobial therapy. However, clinicians' trust and acceptance of these tests will determine their application in practice. Objectives To examine ICU prescribers' views on the application of molecular diagnostics in patients with suspected hospital-acquired and ventilator-associated pneumonia (HAP/VAP). Methods Sixty-three ICU clinicians from five UK hospitals completed a cross-sectional questionnaire between May 2020 and July 2020 assessing attitudes towards using molecular diagnostics to inform initial agent choice and to help stop broad-spectrum antibiotics early. Results Attitudes towards using molecular diagnostics to inform initial treatment choices and to stop broad-spectrum antibiotics early were nuanced. Most (83%) were positive about molecular diagnostics, agreeing that using results to inform broad-spectrum antibiotic prescribing is good practice. However, many (58%) believed sick patients are often too unstable to risk stopping broad-spectrum antibiotics based on a negative result. Conclusions Positive attitudes towards the application of molecular diagnostics to improve antibiotic stewardship were juxtapositioned against the perceived need to initiate and maintain broad-spectrum antibiotics to protect unstable patients. [ABSTRACT FROM AUTHOR]

Background: Antimicrobial resistance (AMR) is a critical global issue that poses significant threats to human health, animal welfare, and the environment. With the increasing emergence of resistant microorganisms, the effectiveness of current antimicrobial medicines against common infections is diminishing. This study aims to conduct a competitive meta-analysis of surveillance data on resistant microorganisms and their antimicrobial resistance patterns in two countries, Egypt and the United Kingdom (UK). Methods: Data for this study were obtained from published reports spanning the period from 2013 to 2022. In Egypt and the UK, a total of 9,751 and 10,602 food samples were analyzed, respectively. Among these samples, 3,205 (32.87%) in Egypt and 4,447 (41.94%) in the UK were found to contain AMR bacteria. Results: In Egypt, the predominant resistance was observed against β-lactam and aminoglycosides, while in the United Kingdom, most isolates exhibited resistance to tetracycline and β-lactam. The findings from the analysis underscore the increasing prevalence of AMR in certain microorganisms, raising concerns about the development of multidrug resistance. Conclusion: This meta-analysis sheds light on the escalating AMR problem associated with certain microorganisms that pose a higher risk of multidrug resistance development. The significance of implementing One Health AMR surveillance is emphasized to bridge knowledge gaps and facilitate accurate AMR risk assessments, ensuring consumer safety. Urgent actions are needed on a global scale to combat AMR and preserve the effectiveness of antimicrobial treatments for the well-being of all living beings. Highlights: 1. Egypt and the United Kingdom (UK) have the highest prevalence rates of E. coli. 2. Chicken has the highest prevalence of microbial resistance strains. 3. Egypt has the highest rate of β-lactam and aminoglycoside resistance. 4. UK has the highest rate of tetracycline and β-lactam resistance. 5. Resistance to multiple drugs has been identified in both nations. [ABSTRACT FROM AUTHOR]

Background Accurate surveillance of livestock antibiotic usage (ABU) at the farm level is an increasingly important part of national antibiotic stewardship initiatives. Numerous ABU indicators or metrics have been developed in Europe and North America but the comparability of these metrics is poorly understood. For policymakers, understanding the relationship between metrics is important when considering the risks posed by ABU and how to regulate them, at the national level, and regulate international trade access in livestock products between countries who use different ABU metrics. Objectives To quantify the patterns of ABU among beef (cattle) and lamb (sheep) production systems. To explore ABU variation between farm types across seven ABU metrics developed in Europe and North America using a common dataset of sheep and beef farms' antibiotic purchases from the UK. Methods A dataset of >16 200 antibiotic sales events to 686 farm enterprises of different types underwent quantitative analysis. Correlation matrixes were generated for seven international ABU metrics. Results ABU was significantly higher among calf-rearers. Across all farm types, tetracyclines and β-lactams were the predominant groups by mass, but represent a similar dose equivalent to macrolides across most farm types. Good agreement (>0.9) was observed between metrics. Conclusions Reliable metrics to accurately benchmark farms are crucial for maintaining confidence of farmers in the fairness of any surveillance system, especially when the ranking of any given system may be linked to financial subsidies or penalties and also when negotiating import and export access for livestock products between countries. [ABSTRACT FROM AUTHOR]

The plans for a new antimicrobial utilization and resistance national surveillance programme, alongside the development of quality measures and methods to monitor unintended outcomes of antimicrobial stewardship and both public and professional behaviour interventions were published in 2013. Since then, England has published an annual surveillance report including outlining progress against the ambitions of the UK national action plans on antimicrobial resistance (2013 to 2018 and 2019 to 2024). A decade later we provide a brief update on progress so far, with a focus on key highlights from the latest report published in November 2022. We also provide our recommendations for areas of focus as we move into the next decade. From an initial focus on antibiotic consumption and resistance, the report now includes surveillance data for antifungals, antivirals (including novel agents, such as those targeting SARS-CoV-2) and antimalarials. Evaluation of key stewardship interventions including professional and public engagement initiatives are also reported, as well as progress against NHS England's (NHSE's) improvement measures. [ABSTRACT FROM AUTHOR]

Background: Overtreatment poses a challenge to healthcare systems due to harmful consequences of avoidable side-effects and costs. This study presents the first account for examining the feasibility of placebo use for reducing overtreatment in primary care, including whether public attitudes support the use of different placebo types in place of inappropriate prescriptions of antibiotics, antidepressants, or analgesics. Methods: We used a multi-study, mixed-methods design, including patient and public (PPI) consultations, focus groups (Study 1) and two pre-registered online experiments (Studies 2 and 3). Results: Study 1 (N = 16) explored everyday conceptions and practicalities of potential placebo use in the context of respiratory infections. Findings highlighted the importance of trusting doctor-patient relationships and safety-netting. Study 2 employed a randomised experiment with a representative UK sample (N = 980), investigating attitudes towards 5 different treatment options for respiratory infections: (1) blinded + pure placebo, (2) open-label + pure placebo, (3) open-label + impure placebo, (4) antibiotic treatment, and (5) no treatment. Study 2 also examined how attitudes varied based on wording and individual differences. Findings indicated general support (ηp2 =.149, large effect size) for replacing inappropriate antibiotics with open-label + impure placebos, although personal placebo acceptability was lower. Also, older people, individuals suffering from chronic illness or those showing higher levels of health anxiety appeared less amenable to placebo use. Study 3 (N = 1177) compared attitudes towards treatment options across three clinical scenarios: respiratory infection, depression and pain. Findings suggested significant differences in the acceptability of placebo options based on the clinical context. In the infection scenario, options for open-label + pure placebos, open-label + impure placebos and no treatment were rated significantly more acceptable (ηp2 =.116, medium effect size) compared to the depression and pain scenarios. Again, general support for placebos was higher than placebo acceptability for personal use. Conclusions: Findings from PPI and three studies indicate general support for combatting overprescribing in primary care through clinical placebo use. This is an indicator for wider UK public support for a novel, behavioural strategy to target a long-standing healthcare challenge. General acceptability appears to be highest for the use of open-label + impure placebos in the context of antibiotic overprescribing. [ABSTRACT FROM AUTHOR]

Background: On admission to hospital, patients with community-acquired pneumonia (CAP), undergo extensive diagnostic testing. Two high-throughput laboratory-based PCR panels which return a result in 5.5 hours (h) have been developed to test for pathogens commonly associated with upper (Respiratory 1 Panel) and lower (Respiratory 3 Panel) respiratory tract infections (GeneFirst, Oxford). These could replace multiple diagnostic tests currently used. Methods: An online survey, completed by senior clinicians in the UK, France and Spain, was used to collect data on the diagnostic testing of immunocompetent and immunocompromised adults admitted to hospital with CAP, including the cost of diagnostics. Data were used to inform a cost-comparison model. For each country, the average cost of diagnostic testing per patient was calculated separately for immunocompetent and immunocompromised patients. The model compared three testing strategies with standard of care (SoC). In the Panel 1 strategy, the Respiratory 1 Panel was used for patients that would otherwise have tests which could be replaced by Respiratory 1 Panel, equivalent strategies for Respiratory 3 Panel and for both panels combined were assessed. Results: In total, 48 surveys were completed (UK = 17; France = 15; Spain = 16). Compared with SoC, the Panel 1 + 3 strategy was most favourable, resulting in cost savings for immunocompetent and immunocompromised patients respectively, of €22.09 (£18.50) and €26.12 (£21.88) in the UK, €99.60 and €108.77 in France and €27.07 and €51.87 in Spain. Conclusion: In all three countries, the use of these respiratory panels could reduce the average cost of diagnostics used for patients admitted to hospital with CAP. [ABSTRACT FROM AUTHOR]

Objectives: To describe antibiotic prescription by veterinarians in general practices in the United Kingdom before referral and analyse if UK antibiotic stewardship guidelines were followed. Materials and Methods: The clinical records from dogs and cats referred to the Internal Medicine and Oncology departments of two referral hospitals were retrospectively reviewed. Results: There were 917 cases included, of which 486 (53.0%) had been prescribed antibiotics for the presentation they were subsequently referred for. Bacterial culture or cytology to guide antibiotic prescription had been performed in 43 of 486 (8.8%) and nine of 486 cases (1.8%) respectively. In four cases, both cytology and culture were performed. For those animals who had received antibiotics, 344 of 486 (70.8%) prescriptions did not comply with UK antibiotic stewardship guidelines. Following investigations at a referral centre, a bacterial aetiology was found or suspected in 17.9% of the cases that received antibiotics. Clinical Significance: Use of diagnostics, including culture and cytology, to prove or determine the likelihood of a bacterial aetiology was infrequently performed before referral and may have contributed to overprescription of antibiotics. Encouraging veterinarians to undertake appropriate diagnostics, in combination with education around compliance with antibiotic stewardship guidelines, might reduce antibiotic prescription. [ABSTRACT FROM AUTHOR]

Background: Antimicrobial resistance (AMR) is a major global health threat caused by the inappropriate use of antimicrobials in healthcare and other settings. Antimicrobial stewardship (AMS) is a broad multi-component health services intervention that promotes and monitors the judicious use of antimicrobials to preserve their future effectiveness. A main component of AMS is education and training (E&T). However, there are often discrepancies in how such interventions are implemented and delivered in hospital-based care. The aim of this study was to explore the factors influencing the implementation of AMS E&T in UK hospitals. Methods: Semi-structured interviews were carried out with AMS E&T trainers in UK hospitals. The interview schedule was developed using the Capability, Opportunity, Motivation = Behaviour (COM-B) model. Participants were identified via professional networks and social media. Interviews were analysed using inductive thematic analysis, followed by deductive analysis using the COM-B model as a framework. Results: A total of 34 participants (26 antimicrobial pharmacists, 3 nurses, 1 advanced clinical practitioner, 2 infectious disease consultants, 1 microbiologist and 1 clinical scientist). responsible for designing, implementing and evaluating AMS E&T in UK hospitals (five from Northern Ireland, four from Wales, two from Scotland and 23 from England) took part in virtual interviews. Key themes were: (1) The organisational context, including system-level barriers to AMS included competing organisational targets (Reflective motivation and physical opportunity) and the impact of the COVID-19 pandemic on activity (Physical opportunity); (2) Healthcare professionals' roles and the wider multi-disciplinary team, such that AMS roles were defined and addressed poorly in E&T (Social opportunity); and (3) The individual perception of the need for AMS E&T in hospital-based care, manifest in a perceived lack of conviction of the wider threat of AMR and the resulting need for AMS E&T (Reflective motivation). Conclusion: This study has identified factors influencing implementation of AMS E&T in UK hospitals and further identified where implemented, AMS E&T did not address real-world challenges. Current AMS E&T needs to be optimised to elicit practice change, with recommendations including training and engaging the wider work-force and drawing upon theoretically-informed intervention development frameworks to inform AMS E&T to better target AMS behaviour change. [ABSTRACT FROM AUTHOR]

The article discusses the tasks of emergency nurses in infection prevention and control in emergency departments (ED) in the U.K. Topics covered include the main pathogens linked to infection, and the importance of reducing their transmission risk to lessen the hospital stay, mortality and morbidity of patients and improving their experience. Also noted are the antimicrobial stewardship responsibility of all clinicians, and the emergency nurse's role in implementing them.

Introduction: Antifungal stewardship (AFS) programs are recognized to contribute to optimizing antifungal prescribing for treatment and prophylaxis. However, only a small number of such programs are implemented. Consequently, evidence on behavioral drivers and barriers of such programs and learnings from existing successful AFS programs is limited. This study aimed to leverage a large AFS program in the UK and derive learnings from it. The objective was to (a) investigate the impact of the AFS program on prescribing habits, (a) use a Theoretical Domains Framework (TDF) based on the COM-B (Capability, Opportunity, and Motivation for Behavior) to qualitatively identify drivers and barriers for antifungal prescribing behaviors across multiple specialties, and (c) semiquantitatively investigate trends in antifungal prescribing habits over the last 5 years. Methods: Qualitative interviews and a semiquantitative online survey were conducted across hematology, intensive care, respiratory, and solid organ transplant clinicians at Cambridge University Hospital. The discussion guide and survey used were developed to identify drivers of prescribing behavior, based on the TDF. Results: Responses were received from 21/25 clinicians. Qualitative outcomes demonstrated that the AFS program was effective in supporting optimal antifungal prescribing practices. We found seven TDF domains influencing antifungal prescribing decisions—five drivers and two barriers. The key driver was collective decision-making among the multidisciplinary team (MDT) while key barriers were lack of access to certain therapies and fungal diagnostic capabilities. Furthermore, over the last 5 years and across specialties, we observed an increasing tendency for prescribing to focus on more targeted rather than broad-spectrum antifungals. Conclusions: Understanding the basis for linked clinicians' prescribing behaviors for identified drivers and barriers may inform interventions on AFS programs and contribute to consistently improving antifungal prescribing. Collective decision-making among the MDT may be leveraged to improve clinicians' antifungal prescribing. These findings may be generalized across specialty care settings. [ABSTRACT FROM AUTHOR]

Overprescribing of antibiotics in paediatrics accounts for a significant proportion of inappropriate antibiotic use in human healthcare, thereby contributing to the global health emergency of antimicrobial resistance. Antimicrobial stewardship efforts are complicated by the unique social dynamics in paediatric healthcare, with a specific challenge being the prominent role of parents and carers who act as intermediaries between prescribers and paediatric patients. In this Perspective article concentrating on healthcare of the United Kingdom, we describe this complicated interplay of different decision stakeholders (patients, parents and prescribers), outline four dimensions of decision challenges (social, psychological, systemic and specific diagnostic and treatment challenges) and provide a number of theory-based strategies for supporting different stakeholders during the decision process, ultimately with the aim of improving antimicrobial stewardship. Key decision challenges for patients and carers include limited knowledge and experience of managing infections, which were exacerbated during the COVID-19 pandemic and frequently result in health anxiety and inappropriate health-seeking behaviours. Challenges for medical prescribers span societal pressures from prominent patient litigation cases, cognitive biases, and system pressures to specific diagnostic problems (e.g., age limitations of current clinical scoring systems). Strategies for mitigating decision challenges in paediatric infection management will need to include a range of context- and stakeholder-specific actions, including improvements of integrated care and public health education as well as better clinical decision tools and access to evidence-based guidelines. [ABSTRACT FROM AUTHOR]

The article reports on a study highlighting concerns about antibiotic underdosing and improper disposal practices in NHS organizations across the Great Britain, which may contribute to antimicrobial resistance (AMR). It also discusses the challenges of ensuring full dose delivery during intravenous administration, the impact of residual volumes in infusion lines, and the need for improved flushing practices and guidelines to combat AMR.

Background: The 'STARWAVe' clinical prediction rule (CPR) uses seven factors to guide risk assessment and antibiotic prescribing in children with cough (Short illness duration, Temperature, Age, Recession, Wheeze, Asthma, Vomiting). Aim: To assess the influence of STARWAVe factors on GPs' unaided risk assessments and prescribing decisions. Design and setting: Clinical vignettes administered to 188 UK GPs online. Method: GPs were randomly assigned to view 32 (out of a possible 64) vignettes online depicting children with cough. The vignettes comprised the seven STARWAVe factors, which were varied systematically. For each vignette, GPs assessed risk of deterioration in one of two ways (sliding-scale versus risk-category selection) and indicated whether they would prescribe antibiotics. Finally, GPs saw an additional vignette, suggesting that the parent was concerned. Mixed-effects regressions were used to measure the influence of STARWAVe factors, risk-elicitation method, and parental concern on GPs' assessments and decisions. Results: Six STARWAVe risk factors correctly increased GPs' risk assessments (bssliding-scale≥0.66, odds ratios [ORs]category-selection≥1.75, Ps≤0.001), whereas one incorrectly reduced them (short illness duration: bsliding-scale −0.30, ORcategory-selection 0.80, P≤0.039). Conversely, one STARWAVe factor increased prescribing odds (temperature: OR 5.22, P<0.001), whereas the rest either reduced them (short illness duration, age, and recession: ORs≤0.70, Ps<0.001) or had no significant impact (wheeze, asthma, and vomiting: Ps≥0.065). Parental concern increased risk assessments (bsliding-scale 1.29, ORcategory-selection 2.82, P≤0.003) but not prescribing odds (P = 0.378). Conclusion: GPs use some, but not all, STARWAVe factors when making unaided risk assessments and prescribing decisions. Such discrepancies must be considered when introducing CPRs to clinical practice. [ABSTRACT FROM AUTHOR]

Background: Antimicrobial stewardship (AMS) is an intervention, which ensures the appropriateness of antimicrobial use to avoid in part the rising problem of antimicrobial resistance and negative effects of inappropriate antimicrobial use. In the solid organ transplant (SOT) population, which is prone to a particularly high risk of infection resulting from immunosuppression and anatomical issues with each type of SOT, the need for good stewardship has never been more important. This article looks at current AMS practice in SOT units in the United Kingdom and how things could be improved in the future. Methods: The current practice of AMS alongside national antimicrobial resistance rates were reviewed using national mandatory reporting data. The background to the current practice and policies in place in the National Health Service (NHS) were also reviewed and possibilities for future approaches explored. Results: AMS is a requirement within all NHS hospitals in the United Kingdom as per government policy. Mandatory reporting of specific bloodstream infections (BSIs) and antimicrobial consumption alongside financial incentives has been the approach nationwide. Gram‐negative resistance rates in BSIs have been increasing prior to the COVID‐19 pandemic. Little SOT‐specific data on antimicrobial resistance exists, and the general approach to AMS in SOT units has generally modeled the national approach. Conclusion: Although there is a good, standardized approach to AMS in the NHS, there is a need for SOT‐specific AMS approaches to be developed in the United Kingdom. More data is required on antimicrobial resistance rates, and studies are needed to investigate optimal antimicrobial prophylaxis regimens for each solid organ group. Tools to aid AMS efforts and novel treatment options for complex multiresistant infection must also be explored amongst transplant centers. [ABSTRACT FROM AUTHOR]

Objectives: This study sought to analyze the outpatient parenteral antimicrobial therapy (OPAT) services provided by a tertiary hospital, in terms of types and duration of antimicrobials administered, and assess whether these services were in line with current good practice recommendations. Methods: The electronic healthcare records of all stable patients with infectious diseases, aged ≥ 18 years, who received OPAT services between January 2019 and March 2021, were analyzed. For statistical analysis, the patients were divided into younger (< 65 years) and older (≥ 65 years) adults and the difference between them, in terms of healthcare resources utilization, was assessed. Results: Over 27 months, 199 patients received OPAT services, resulting in saving of 7514 bed-days. Bone and joint infections (38.7%) were the predominant diagnoses. The median actual OPAT duration was significantly greater than the planned duration for the total study population, younger adults, and older adults (p < 0.050). Of 28 (14.1%) patients with adverse events, 25 were related to antimicrobials while the remaining three were associated with catheters. There were no significant differences between younger and older adults in the characteristics evaluated, except for the higher incidence of Staphylococcus aureus (p < 0.001) and Escherichia coli, Staphylococcal spp., Streptococcal spp., and Pseudomonas spp. (p = 0.003) infection in older adults. Conclusions: The actual median duration of OPAT therapy was significantly longer than planned, with suboptimal adherence to the principles of antimicrobial stewardship. OPAT has been shown to be safe for both younger and older adults. [ABSTRACT FROM AUTHOR]

Diagnosis of urinary tract infections (UTI) is a routine part of medical work and yet is well recognised to be an area of high clinical uncertainty. Meanwhile, diagnosis of UTI is becoming increasingly important to policymakers globally due to concerns about antibiotic over-prescription. Drawing on Mol's concept of ontological multiplicity in clinical work, I explore how diagnostic uncertainty is co-ordinated into certainty by a UK national diagnostic algorithm for UTI. The diagnosis of UTI is produced or withheld as a post hoc rationalisation of a prior decision whether to prescribe antibiotics or not. Work in the sociology of diagnosis has already noted that diagnostic steps are often re-ordered by health-care professionals taking diverse actions in the best interest of their patients. This article contributes an argument that ordering diagnostic work around antimicrobial stewardship agendas has the effect of narrowing possible actions. Exploring the consequences and effects of doing diagnosis in this way for different groups, I argue that a greater creativity about what could be done to care for painful bladders could be found in a return to more clinical ways of working., (© 2024 The Author(s). Sociology of Health & Illness published by John Wiley & Sons Ltd on behalf of Foundation for the Sociology of Health & Illness.)

Background: Urinary tract infection is the most diagnosed infection in older people. It accounts for more than 50% of antibiotic prescriptions in care homes and is a frequent reason for care home residents being hospitalised., Objective: This realist review developed and refined programme theories for preventing and recognising urinary tract infection, exploring what works, for whom and in what circumstances., Design: The review used realist synthesis to explore existing literature on the detection and prevention of urinary tract infection, complemented by stakeholder consultation. It applies to the UK context, although other healthcare systems may identify synergies in our findings., Data Sources: Bibliographic databases searched included MEDLINE, CINAHL, EMBASE, Cochrane Library, Web of Science Core Collection (including the Social Sciences Citation Index), Sociological Abstracts, Bibliomap and National Institute for Health and Care Research Journals Library., Data Selection and Extraction: Title and abstract screening were undertaken by two researchers independently of each other. Selection and assessment were based on relevance and rigour and cross-checked by a second researcher. Data extracted from the included studies were explored for explanations about how the interventions were considered to work (or not). Evidence tables were constructed to enable identification of patterns across studies that offered insight about the features of successful interventions., Data Analysis and Synthesis: Programme theories were constructed through a four-stage process involving scoping workshops, examination of relevant extant theory, analysis and synthesis of primary research, teacher-learner interviews and a cross-system stakeholder event. A process of abductive and retroductive reasoning was used to construct context-mechanism-outcome configurations to inform programme theory., Results: The scoping review and stakeholder engagement identified three theory areas that address the prevention and recognition of urinary tract infection and show what is needed to implement best practice. Nine context-mechanism-outcome configurations provided an explanation of how interventions to prevent and recognise urinary tract infection might work in care homes. These were (1) recognition of urinary tract infection is informed by skills in clinical reasoning, (2) decision-support tools enable a whole care team approach to communication, (3) active monitoring is recognised as a legitimate care routine, (4) hydration is recognised as a care priority for all residents, (5) systems are in place to drive action that helps residents to drink more, (6) good infection prevention practice is applied to indwelling urinary catheters, (7) proactive strategies are in place to prevent recurrent urinary tract infection, (8) care home leadership and culture fosters safe fundamental care and (9) developing knowledgeable care teams., Limitations: We adapted our approach and work to online interactions with stakeholders and as a research team because of COVID-19. This also had an impact on bringing stakeholders together at a face-to-face event at the end of the project. Studies focusing on the prevention of urinary tract infection in care home settings were predominantly from the USA and Europe where the regulatory and funding systems for the long-term care of the elderly have some differences, particularly in the USA where national reporting plays a significant role in driving improvements in care., Conclusions: Care home staff have a vital role in the prevention and recognition of urinary tract infection, which can be enabled through integration and prioritisation within the systems and routines of care homes and delivery of person-centred care. Promoting fundamental care as a means of facilitating a holistic approach to prevention and recognition of urinary tract infection helps staff to recognise how they can contribute to antimicrobial stewardship and recognition of sepsis. Challenging assumptions made by staff about the presentation of urinary tract infection is complex and requires education that facilitates 'unlearning' and questioning of low-value practices. Programmes to prevent urinary tract infection need to be co-designed and supported through active and visible leadership by care home managers with support from specialist practitioners., Future Work: We will focus on co-designing tools that facilitate implementation of our findings to ensure they fit with the care home context and address some of the challenges faced by care home leaders. This will underpin action at care home and system levels. Further research is needed to better understand the perspectives of residents and family carers, the effectiveness of non-pharmacological, pharmacological and specialist practitioner interventions and non-traditional approaches to training and educating the workforce in care home settings., Study Registration: This study is registered as PROSPERO CRD42020201782., Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR130396) and is published in full in Health Technology Assessment ; Vol. 28, No. 68. See the NIHR Funding and Awards website for further award information.

Summary: Monitoring the use of antimicrobial drugs is an important component of antimicrobial stewardship. The objective of this clinical audit was to record the total annual quantities of different antimicrobial drugs prescribed in equine practices over a 5‐year period. Data on antimicrobial use were retrieved from the computerised practice management systems of 11 equine veterinary practices in the UK over the 5‐year period 2014–2018. There was a trend towards decreasing total quantities of antimicrobials prescribed each year from 2014 to 2018. Complete data for all 5 years were available in 6/11 practices. There was a 50% reduction in total antimicrobial usage between 2014 and 2018 in these practices, with a 38% reduction in enrofloxacin, a 95% reduction in ceftiofur and a 100% reduction in cefquinome usage between 2014 and 2018. As a proportion of the total quantities of antimicrobials prescribed, there were significant increases in the proportions of trimethoprim sulphadiazine and doxycycline used, and significant decreases in the proportion of cefquinome used between 2014 and 2018. The annual proportions of procaine penicillin use remained between 5 and 6% over the whole period. A limitation of the study was that data of the numbers and sizes of horses being prescribed the antimicrobials were not available. It was concluded that there was an overall decline in the quantities of antimicrobials prescribed by the 11 general equine practices over the time period of 2014 to 2018, including a reduction in the prescription of the critically important antimicrobials, enrofloxacin, ceftiofur and cefquinome. [ABSTRACT FROM AUTHOR]

The impact of the COVID-19 pandemic on antimicrobial stewardship is a cause for serious concern. There is evidence of increased antibiotic usage in many settings and fears of over-use, especially of broad-spectrum antibiotics in patients with COVID-19, raising concerns about potential impact on antimicrobial resistance globally. At the same time, the pandemic has impacted the provision of education and training throughout the health and education sectors, during a period when health services and staff were under unprecedented pressure. All-Wales Antimicrobial Resistance Educators (AWARE) is an interprofessional network of healthcare professionals whose roles include provision of antimicrobial stewardship education in National Health Service health boards across Wales. The aim of this report was to use AWARE project data to study the impact of the pandemic on the provision of antimicrobial stewardship education and training in healthcare settings in Wales in 2020, compared to 2019. Overall, the number of staff reached by education increased by 10%, despite the number of educational sessions falling by 26% and the number of hours of teaching by 43%. Rapid switch to virtual education allowed fewer, shorter, educational sessions, allowing more staff to be reached. [ABSTRACT FROM AUTHOR]

Background: Antimicrobial stewardship is a cornerstone of efforts to combat antimicrobial resistance. We evaluated the impact of a formal discussion of antimicrobial stewardship for dogs and cats on systemic antimicrobial prescribing behaviours among companion animal veterinarians. Methods: Electronic health records including information about the prescription of antimicrobials were collected from a multisite UK veterinary practice between 2017 and 2020. We undertook interrupted time series analysis using a quasi‐Poisson model to compare the pre‐ and postintervention change in level and slope for multiple outcomes. Results: After the intervention, there were sustained reductions in the prescription rate of cefovecin to cats and metronidazole to dogs and increases in amoxicillin‐clavulanic acid prescribing. There was no evidence for an immediate change in overall prescribing rates in either species, although rates increased over the 12 months after the intervention. There was a transient increase in the proportion of dogs who had their weight recorded at the time of prescription. Results suggest decreases in the prescription of off‐licence antimicrobials in both species and the likelihood of underdosing in dogs. Conclusions: Discussion of antimicrobial stewardship is more likely to influence the antimicrobial choice than whether to prescribe or not. Interventions may benefit by focusing on appropriate antimicrobial selection rather than overall prescription frequency. [ABSTRACT FROM AUTHOR]

Background: Avoidance of unnecessary antimicrobial administration is a key tenet of antimicrobial stewardship; knowing the optimal duration of therapy obviates over-treatment. However, little research has been performed to establish course lengths for common canine infections. In clinical practice, antimicrobial therapy is frequently prescribed in dogs presenting lower urinary tract signs (haematuria, pollakiuria and dysuria/stranguria). The proposed length of treatment in International Consensus guidelines has decreased with each iteration, but these recommendations remain arbitrary and largely extrapolated from experience in people. Methods: The objective of this prospective, multi-centre study is to find the shortest course duration that is non-inferior to the standard duration of 7 days of amoxicillin/clavulanate in terms of clinical outcomes for female dogs with lower urinary tract signs consistent with a urinary tract infection. An electronic data capture platform will be used by participating veterinarians working in clinical practice in the United Kingdom. Eligible dogs must be female, aged between 6 months and 10 years and have lower urinary tract signs of up to seven days' duration. Enrolment will be offered in cases where the case clinician intends to prescribe antimicrobial therapy. Automatic pseudo-randomisation to treatment group will be based on the day of presentation (Monday-Friday); all antimicrobial courses will be completed on the Sunday after presentation generating different treatment durations. Follow-up data will be collected 1, 8 and 22–26 days after completion of the antimicrobial course to ensure effective safety netting, and to monitor short-term outcome and recurrence rates. Informed owner consent will be obtained in all cases. The study is approved by the Ethical Review Board of the University of Nottingham and has an Animal Test Certificate from the Veterinary Medicine's Directorate. Discussion: This study has been designed to mirror current standards of clinical management; conclusions should therefore, be widely applicable and guide practising veterinarians in their antimicrobial decision-making process. A duration-response curve will be created allowing determination of the optimal treatment duration for the management of female dogs with lower urinary tract signs. It is hoped that these results will contribute valuable information to improve future antimicrobial stewardship as part of a wider one-health perspective. [ABSTRACT FROM AUTHOR]

Background: Rapid molecular diagnostic tests to investigate the microbial aetiology of pneumonias may improve treatment and antimicrobial stewardship in intensive care units (ICUs). Clinicians' endorsement and uptake of these tests is crucial to maximise engagement; however, adoption may be impeded if users harbour unaddressed concerns or if device usage is incompatible with local practice. Accordingly, we strove to identify ICU clinicians' beliefs about molecular diagnostic tests for pneumonias before implementation at the point-of-care. Methods: We conducted semi-structured interviews with 35 critical care doctors working in four ICUs in the United Kingdom. A clinical vignette depicting a fictitious patient with signs of pneumonia was used to explore clinicians' beliefs about the importance of molecular diagnostics and their concerns. Data were analysed thematically. Results: Clinicians' beliefs about molecular tests could be grouped into two categories: perceived potential of molecular diagnostics to improve antibiotic prescribing (Molecular Diagnostic Necessity) and concerns about how the test results could be implemented into practice (Molecular Diagnostic Concerns). Molecular Diagnostic Necessity stemmed from beliefs that positive results would facilitate targeted antimicrobial therapy; that negative results would signal the absence of a pathogen, and consequently that having the molecular diagnostic results would bolster clinicians' prescribing confidence. Molecular Diagnostic Concerns included unfamiliarity with the device's capabilities, worry that it would detect non-pathogenic bacteria, uncertainty whether it would fail to detect pathogens, and discomfort with withholding antibiotics until receiving molecular test results. Conclusions: Clinicians believed rapid molecular diagnostics for pneumonias were potentially important and were open to using them; however, they harboured concerns about the tests' capabilities and integration into clinical practice. Implementation strategies should bolster users' necessity beliefs while reducing their concerns; this can be accomplished by publicising the tests' purpose and benefits, identifying and addressing clinicians' misconceptions, establishing a trial period for first-hand familiarisation, and emphasising that, with a swift (e.g., 60–90 min) test, antibiotics can be started and refined after molecular diagnostic results become available. [ABSTRACT FROM AUTHOR]

Background: Antimicrobial usage and stewardship programmes during COVID-19 have been poorly studied. Prescribing practice varies despite national guidelines, and there is concern that stewardship principles have suffered. Aim: To analyse antibiotic prescriptions during the COVID-19 pandemic at a teaching hospital and to propose improved approaches to stewardship. Methods: We reviewed COVID-19 admissions to medical wards and intensive care units (ICUs) in a London teaching hospital to assess initial antibiotic usage and evidence of bacterial co-infection, and to determine if our current antibiotic guidelines were adhered to. Findings: Data from 130 inpatients (76% medical and 24% ICU) were obtained. On admission, 90% were treated with antibiotics. No microbiological samples taken on admission provided definitive evidence of respiratory co-infection. In 13% of cases, antibiotics were escalated, usually without supporting clinical, radiological or laboratory evidence. In 16% of cases, antibiotics were stopped or de-escalated within 72 h. Blood results and chest radiographs were characteristic of COVID-19 in 20% of ward patients and 42% of ICU patients. Overall mortality was 25% at 14 days – similar to rates described for the UK as a whole. Conclusion: The majority of patients received antibiotics despite limited evidence of co-infection. Most patients received narrower spectrum antibiotics than recommended by NICE. As understanding of the natural history of COVID-19 infections progresses, stewardship programmes will need to evolve; however, at this point, we feel that a more restrictive antibiotic prescribing approach is warranted. We propose strategies for effective stewardship and estimate the effect this may have on antibiotic consumption. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 pandemic has altered the context for antimicrobial stewardship in primary care.Aim: To assess the effect of the pandemic on antibiotic prescribing, accounting for changes in consultations for respiratory and urinary tract infections (RTIs/UTIs).Design and Setting: Population-based cohort study using the UK Clinical Practice Research Datalink (CPRD) GOLD database from January 2017 to September 2020.Method: Interrupted time-series analysis evaluated changes in antibiotic prescribing and RTI/UTI consultations adjusting for age, sex, season, and secular trends. The authors assessed the proportion of COVID-19 episodes associated with antibiotic prescribing.Results: There were 253 655 registered patients in 2017 and 232 218 in 2020, with 559 461 antibiotic prescriptions, 216 110 RTI consultations, and 36 402 UTI consultations. Compared with prepandemic months, March 2020 was associated with higher antibiotic prescribing (adjusted rate ratio [ARR] 1.13; 95% confidence interval [CI] = 1.11 to 1.16). Antibiotic prescribing fell below predicted rates between April and August 2020, reaching a minimum in May (ARR 0.73; 95% CI = 0.71 to 0.75). Pandemic months were associated with lower rates of RTI/UTI consultations, particularly in April for RTIs (ARR 0.23; 95% CI = 0.22 to 0.25). There were small reductions in the proportion of RTI consultations with antibiotic prescribed and no reduction for UTIs. Among 25 889 COVID-19 patients, 2942 (11%) had antibiotics within a COVID-19 episode.Conclusion: Pandemic months were initially associated with increased antibiotic prescribing, which then fell below expected levels during the national lockdown. Findings are reassuring that antibiotic stewardship priorities have not been neglected because of COVID-19. Research is required into the effects of reduced RTI/UTI consultations on incidence of serious bacterial infections. [ABSTRACT FROM AUTHOR]

This article critically analyses the prevalence, assessment and management of urinary tract infections (UTIs) in patients over the age of 65, in an urgent care out-of-hours service in order to enhance care. It is undertaken from the perspective of working as an Advanced Nurse Practitioner (ANP). A synopsis of UTI is presented, examining the epidemiology and aetiology. The process of assessment, diagnosis and management of UTI in older people is appraised based on current evidence. Difficulties associated with the recognition of UTI in elderly are evaluated. Finally, recommendations are made for the improvement of future practice as an ANP. [ABSTRACT FROM AUTHOR]

Since the beginning of 2020, the COVID-19 pandemic has been a challenge faced by the world and one that all health professionals are facing. The impact of COVID-19 on patients receiving and accepting healthcare services has changed over the past few months. identified within our burns network was a change in the mechanism of burn injuries in children for example, an increase of steam inhalation burns has been seen (Brewster et al, 2020) and an overall change in the approach to burn care. This paper is an initial glance at what was identified at an acute setting during the first wave of pandemic. [ABSTRACT FROM AUTHOR]

More than 4.3 million people in the UK have been diagnosed with diabetes and there are thought to be a further 850 000 people living with diabetes who have not yet been diagnosed (Diabetes UK, 2024). Around half of all adults who have diabetes experience bladder dysfunction. It is one of the most common complications of diabetes, yet there is little in the medical literature and it is often unrecognised and poorly treated (Wittig et al, 2019). This article uses a case history approach to examine how diabetes can affect the bladder.

Background: Monitoring antibiotic usage is an important part of tackling antimicrobial resistance. The use of computerised records for monitoring has been previously described in the equine sector but there is currently no consensus on metrics used to report usage., Objectives: To document antibiotic use in equine practices in the United Kingdom over a 10-year period using commercially available practice management software., Study Design: Retrospective survey., Methods: A custom antibiotic usage report was created using Eclipse® practice management software. Participating practices were given instructions on how to generate the usage report. Annual reports were requested for a 10-year period (2012-2021 inclusive). Each report provided sales of each class of antibiotic in total mg and in mg/kg, based on the number of equids treated (for any transaction) and their average weight. The defined daily dose for animals (DDDvet) and the DDD/1000 (used in people) were also calculated to correct for variation in dosage rates between antibiotics., Results: Fourteen practices submitted data for an annual maximum of 107 977 horses. Overall, median annual antibiotic usage was 54.25 mg/kg (range 45.34-60.27 mg/kg), 1.52 defined daily doses/animal/year (range 1.39-1.70) and 4.17 defined daily dose/1000 animals (range 3.82-4.66). Overall median highest priority critically important antimicrobial usage was 0.67 mg/kg (range 0.56-1.71), 0.12 defined daily doses/animal/year (range 0.10-0.14) and 0.33 defined daily dose/1000 animals (range 0.29-0.39)., Main Limitations: The software relied on the accurate identification of antibiotic preparations. The calculation of DDDvet was complicated by the varying dose rates of antimicrobials used in equine practice., Conclusions: A reliable technique to measure antibiotic usage is presented. Defined daily dosage calculations may be more helpful in equine practice due to the preponderance of potentiated sulphonamides usage. These data and methods may provide the basis for future clinical audits aiming to enhance antimicrobial stewardship., (© 2023 The Authors. Equine Veterinary Journal published by John Wiley & Sons Ltd on behalf of EVJ Ltd.)

To investigate the incidence of bacterial and fungal coinfection of hospitalized patients with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in this retrospective observational study across two London hospitals during the first UK wave of coronavirus disease 2019 (COVID-19). A retrospective case series of hospitalized patients with confirmed SARS-CoV-2 by PCR was analysed across two acute NHS hospitals (20 February–20 April 2020; each isolate reviewed independently in parallel). This was contrasted to a control group of influenza-positive patients admitted during the 2019–2020 flu season. Patient demographics, microbiology and clinical outcomes were analysed. A total of 836 patients with confirmed SARS-CoV-2 were included; 27 (3.2%) of 836 had early confirmed bacterial isolates identified (0–5 days after admission), rising to 51 (6.1%) of 836 throughout admission. Blood cultures, respiratory samples, pneumococcal or Legionella urinary antigens and respiratory viral PCR panels were obtained from 643 (77%), 110 (13%), 249 (30%), 246 (29%) and 250 (30%) COVID-19 patients, respectively. A positive blood culture was identified in 60 patients (7.1%), of which 39 were classified as contaminants. Bacteraemia resulting from respiratory infection was confirmed in two cases (one each community-acquired Klebsiella pneumoniae and ventilator-associated Enterobacter cloacae). Line-related bacteraemia was identified in six patients (three Candida, two Enterococcus spp. and one Pseudomonas aeruginosa). All other community-acquired bacteraemias (n = 16) were attributed to nonrespiratory infection. Zero concomitant pneumococcal, Legionella or influenza infection was detected. A low yield of positive respiratory cultures was identified; Staphylococcus aureus was the most common respiratory pathogen isolated in community-acquired coinfection (4/24; 16.7%), with pseudomonas and yeast identified in late-onset infection. Invasive fungal infections (n = 3) were attributed to line-related infections. Comparable rates of positive coinfection were identified in the control group of confirmed influenza infection; clinically relevant bacteraemias (2/141; 1.4%), respiratory cultures (10/38; 26.3%) and pneumococcal-positive antigens (1/19; 5.3%) were low. We found a low frequency of bacterial coinfection in early COVID-19 hospital presentation, and no evidence of concomitant fungal infection, at least in the early phase of COVID-19. [ABSTRACT FROM AUTHOR]

Background: Suspected urinary tract infection (UTI) syndromes are a common reason for empirical antibiotics to be prescribed in the Emergency Department (ED), but differentiating UTI from other conditions with a similar presentation is challenging. We investigated how often an ED diagnosis of UTI is confirmed clinically/microbiologically, and described conditions which present as UTI syndromes.Methods: Observational study using electronic health records from patients who attended the ED with suspected UTI and had a urine sample submitted for culture. We compared the ED diagnosis to diagnosis at discharge from hospital (ICD-10 codes), and estimated the proportion of cases with clinical/microbiological evidence of UTI.Results: Two hundred eighty nine patients had an ED diagnosis of UTI syndrome comprising: lower UTI (191), pyelonephritis (56) and urosepsis (42). In patients admitted to hospital with an ED diagnosis of lower UTI, pyelonephritis or urosepsis, clinical/microbiological evidence of UTI was lacking in 61/103, 33/54 and 31/42 cases respectively. The ED diagnosis was concordant with the main reason for admission in less than 40% of patients with UTI syndromes, and antibiotics were stopped within 72 h in 37/161 patients.Conclusions: Clinical/microbiological evidence of UTI was lacking in 60-70% of patients, suggesting scope to revise empirical prescribing decisions for UTI syndromes in light of microbial culture and clinical progression. [ABSTRACT FROM AUTHOR]

Introduction: Antimicrobial Resistance (AMR) poses a significant global health threat, with AMR-related deaths projected to reach 10 million annually by 2050. The COVID-19 pandemic has further exacerbated this crisis. This study focuses on evaluating the 'Five Rights of Antibiotic Safety' in an NHS Foundation Trust in England, assessing the impact of the COVID-19 pandemic on antibiotic prescribing and Antimicrobial Stewardship (AMS) practices in 2019 and 2020., Methods: A cross-sectional retrospective study was conducted, focusing on adult patients aged 25 and older admitted to the NHS Foundation Trust and prescribed antibiotics for respiratory tract infections in 2019 and 2020. The study involved a retrospective review of 640 patient records, using descriptive analysis to evaluate the adherence to the 'Five Rights of Antibiotics' and assess the impact of COVID-19 on antibiotic safety practices., Results: The study observed significant shifts in antibiotic prescribing practices during the study period. There was an increase in instances of inappropriate dosing and route of administration, alongside a slight improvement in prescribing durations. The study also noted a stable rate of appropriate antibiotic selection according to antimicrobial guidelines, indicating a concerning rise in inappropriate prescribing patterns during the COVID-19 pandemic., Conclusion: The study revealed notable changes in antibiotic prescribing practices during the COVID-19 pandemic, advocating the importance of robust AMS to ensure appropriate use of antibiotics. The findings highlight the need for enhanced AMS educational initiatives and systematic oversight to combat AMR and protect public health in future health crises., Competing Interests: Competing interest None declared., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

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. [ABSTRACT FROM AUTHOR]

• Clinical outcomes and adverse events (AE) of patients on OPAT reviewed to identify factors associated with success/failure. • In a 10-year period, 2870 patient episodes resulted in 69 610 days of treatment. • 196 AEs were encountered, including 1 case of Clostridium difficile -associated diarrhoea. • AEs occurred in 11% of episodes; rates of drug and line events were 3.3 and 1.78 per 1000 treatment days, respectively. • Understanding OPAT challenges such as AEs and clinical outcomes allows teams to tailor the service to the local population. Outpatient parenteral antibiotic therapy (OPAT) is an established antimicrobial delivery method in the UK. OPAT services differ nationwide, with a paucity of high-quality outcome data to enable benchmarking. A retrospective review of clinical outcomes and adverse events (AEs) of all patients treated during 2008–2017 was performed to identify factors associated with success and failure. Regression models were used to identify factors associated with OPAT success, and AEs were described for the study population using definitions recommended by BSAC. In the 10-year period, 2870 patient episodes resulted in 69 610 days of treatment, with a 91.7% rate of successful therapy completion and 92.0% of infections cured or improved. We encountered 196 AEs, including 1 case of Clostridium difficile -associated diarrhoea. AEs occurred in 10.9% of patient episodes. Adverse drug and line events occurred at a rate of 3.3 and 1.78 per 1000 treatment days, respectively. Rashes, blood dyscrasias and hepatitis were the most common drug AEs. The odds of OPAT success was greater for patients who spent more time (>14 days) on OPAT therapy (OR = 2.32; P < 0.01), utilised a peripheral line (OR = 1.83; P < 0.01), were treated in the clinic compared with self-administration (OR = 2.1; P < 0.02) and did not experience an AE (OR = 0.23; P < 0.01). In our setting, the odds of a successful OPAT episode were associated with longer treatment course, OPAT delivered via a peripheral line, administration in an OPAT clinic setting, and no adverse line or drug events. [ABSTRACT FROM AUTHOR]

Background: The majority of people in long-term care facilities (LTCFs) are aged 65 years and older, and most of their care needs are provided by the LTCF staff. Provision of healthcare services for residents in LTCFs is variable and can result in disjointed care between carers and NHS healthcare professionals.Objectives: Our aim was to understand the use of antibiotics in LTCFs across the UK and to identify potential gaps in knowledge and support for carers and residents when using antibiotics, in order to determine how community pharmacy teams can provide additional support.Methods: A point prevalence survey (PPS) was conducted by community pharmacists (n = 57) when they carried out visits to LTCFs across the UK between 13 November and 12 December 2017. Anonymized data were recorded electronically by the individual pharmacists.Results: Data were analysed for 17909 residents in 644 LTCFs across the UK. The mean proportion of residents on antibiotics on the day of the visit was as follows: 6.3% England (536 LTCFs), 7.6% Northern Ireland (35 LTCFs), 8.6% Wales (10 LTCFs) and 9.6% Scotland (63 LTCFs). The percentage of antibiotics prescribed for prophylactic use was 25.3%. Antibiotic-related training was reported as being available for staff in 6.8% of LTCFs and 7.1% of LTCFs reported use of a catheter passport scheme. Pharmacists conducting the PPS intervened during the survey for 9.5% of antibiotic prescription events; 53.4% of interventions were for clinical reasons and 32.2% were for administration reasons.Conclusions: This survey identified high prophylactic use of antibiotics. There are opportunities for community pharmacy teams to improve antimicrobial stewardship in LTCF settings, including workforce education. [ABSTRACT FROM AUTHOR]

Penicillin allergy records are common, often incorrect and are associated with broad spectrum antibiotic use. We piloted a pharmacist-led multidisciplinary penicillin allergy de-labelling daily ward round to determine the opportunity for penicillin allergy de-labelling in a UK hospital. A daily ward round, delivered by antibiotic pharmacists or junior doctors, identified adult medical and surgical patients between 7 November 2022 and 31 January 2023 with a penicillin allergy record that was preventing first-line penicillin use. An allergy history was taken before risk stratifying likelihood of future harm from penicillin re-exposure and an allergy testing method was determined (direct de-label on history alone or after direct drug provocation testing). After successful allergy de-label, the antibiotic was switched to a penicillin antibiotic. Of 7214 inpatients during the study period, 1133 (15.7%) had a penicillin allergy record. Of 285 allergy histories taken, 105 (36.8%) met high-risk criteria, 45 (15.8%) met low-risk criteria eligible for direct de-label and 73 (25.6%) met criteria eligible for direct drug provocation testing. We were unable to obtain a history for 61 (21.4%) patients. Of 45 low-risk patients eligible for direct de-label, 40 (88.9%) were de-labelled of whom 24 (53.3%) were switched to a penicillin antibiotic. Of 73 patients with a low-risk allergy history eligible for direct drug provocation testing, 16 (21.9%) received direct drug provocation testing, of whom 9 were switched to a penicillin antibiotic. Two direct de-label patients experienced harm (thrush within 5 days and delayed skin reaction after day 5); none of the direct drug provocation testing patients had a reaction by day 5. The switches resulted in reduced alternative antibiotic use by 173 Daily Defined Doses (DDDs). Penicillin allergy de-labelling patient pathway delivered by pharmacists and junior doctors was safe and effective and well accepted by patients and the wider clinical teams. [ABSTRACT FROM AUTHOR]

The authors comment on effort of the United Kingdom's (UK) National Institute for Health and Care Research to explore how to embed penicillin allergy assessment into the National Health Service (NHS). Topics discussed include factor that has driven researchers to explore the safety of non-allergist delivered penicillin allergy de-labelling interventions, and publications that provide toolkits for non-allergy healthcare workers to undertake penicillin allergy de-labelling in the UK.

Healthcare teams have had to evolve and adapt to respond to the burden of antimicrobial resistance (AMR), with pharmacy increasingly leading and participating in local, national and global antimicrobial stewardship (AMS) activities over recent years. This article aims to summarise the evidence base relating to the role of pharmacy teams in AMS and the impact of their activities. Literature searches were undertaken using the online databases MEDLINE (Ovid) and PubMed. A total of 4,134 publications were identified, published in English between 2007-2017, describing any studies involving the role of pharmacy in the human population, and using the following keywords: pharmacist(s), pharmacy(ies), antimicrobial(s), antibiotic(s), resistance and stewardship. Further assessment for relevance, general theme(s) and geographical location of the study and authors resulted in 63 publications selected for further analysis, with a focus on UK activities. Key themes identified include: aims of AMS and the role of pharmacy; AMS strategies in secondary and tertiary care; strategies in primary and community care (such as GP surgeries, community pharmacies and care homes); pharmacy as core part of multidisciplinary AMS teams; education and training about AMR and AMS; and developments in technology enabling innovation in AMS. This article outlines a number of pharmacy roles in AMS. There is, however, a wider scope to further develop these roles providing appropriate integration and infrastructural support is assured. [ABSTRACT FROM AUTHOR]

Objectives: To determine whether local trainer-led TARGET antibiotic interactive workshops improve antibiotic dispensing in general practice.Methods: Using a McNulty-Zelen-design randomized controlled trial within three regions of England, 152 general practices were stratified by clinical commissioning group, antibiotic dispensing rate and practice patient list size, then randomly allocated to intervention (offered TARGET workshop that incorporated a presentation, reflection on antibiotic data, promotion of patient and general practice (GP) staff resources, clinical scenarios and action planning, 73 practices) or control (usual practice, 79 practices). The primary outcome measure was total oral antibiotic items dispensed/1000 patients for the year after the workshop (or pseudo-workshop date for controls), adjusted for the previous year's dispensing.Results: Thirty-six (51%) intervention practices (166 GPs, 51 nurses and 101 other staff) accepted a TARGET workshop invitation. In the ITT analysis total antibiotic dispensing was 2.7% lower in intervention practices (95% CI -5.5% to 1%, P = 0.06) compared with controls. Dispensing in intervention practices was 4.4% lower for amoxicillin/ampicillin (95% CI 0.6%-8%, P = 0.02); 5.6% lower for trimethoprim (95% CI 0.7%-10.2%, P = 0.03); and a non-significant 7.1% higher for nitrofurantoin (95% CI -0.03 to 15%, P = 0.06). The Complier Average Causal Effect (CACE) analysis, which estimates impact in those that comply with assigned intervention, indicated 6.1% (95% CI 0.2%-11.7%, P = 0.04) lower total antibiotic dispensing in intervention practices and 11% (95% CI 1.6%-19.5%, P = 0.02) lower trimethoprim dispensing.Conclusions: This study within usual service provision found that TARGET antibiotic workshops can help improve antibiotic use, and therefore should be considered as part of any national antimicrobial stewardship initiatives. Additional local facilitation will be needed to encourage all general practices to participate. [ABSTRACT FROM AUTHOR]

Background: Antibiotic allergy labels are important barriers to treatment and antimicrobial stewardship, but their prevalence in UK hospitals is poorly described., Objective: To ascertain the prevalence and characteristics of antibiotic allergy labels in a large UK hospital setting and estimate the proportion of penicillin allergy labels for which point-of-care (POC) delabeling assessment would be appropriate., Methods: Electronic health records data were analyzed from all patients treated at Cambridge University Hospitals NHS Foundation Trust in 2019. Validated POC delabeling risk stratification criteria were retrospectively applied to penicillin allergy labels., Results: Recorded reactions to antibiotics were present in 11.8% of all patients (32,148 of 273,216), 16.3% of inpatients (13,874 of 85,230), and 9.7% of outpatients (18,274 of 187,986). Penicillins were the commonest reaction precipitant described (9.0% of patients; 24,646 of 273,216), followed by sulfonamides/trimethoprim (1.4%; 3869 of 273,216) and macrolides/lincosamides (1.3%; 3644 of 273,216). A total of 3.9% of inpatients had recorded reactions to >1 antibiotic class (3348 of 85,230). Cutaneous manifestations were the most commonly described reaction features (40.7% of labels; 15,821 of 38,902). Of 15,949 labels describing probable or possible penicillin "allergy" with sufficient detail to allow for the retrospective assessment of POC delabeling suitability, 1702 were deemed suitable for removal or downgrading of the label to "intolerance" without further investigation (10.7%), 11,887 were appropriate for POC assessment using an oral penicillin challenge (OPC) or OPC with prior bedside skin testing (74.5%), and 2360 were identified as unsuitable for any form of POC assessment (14.8%)., Conclusions: Antibiotic allergy labels are highly prevalent in a UK hospital setting. A large proportion of penicillin allergy labels may be suitable for POC delabeling assessment., (Copyright © 2023 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Outpatient parenteral antimicrobial therapy (OPAT) offers safe, effective and patient-centred care for adults and children. The OPAT UK good practice recommendations for adults and children have recently been updated through a process of literature review, expert consensus and extensive stakeholder consultation. Here we discuss the key changes in the updated recommendations in the context of recent developments, including novel antimicrobial agents and delivery devices, the place of oral antimicrobials as an alternative to intravenous therapy, new OPAT service models and the broader antimicrobial stewardship agenda. [ABSTRACT FROM AUTHOR]

Antibiotic spectrum index (ASI) is a recently developed antimicrobial stewardship (AMS) tool that aims to classify antibiotics based on activity against clinically relevant bacterial pathogens. We utilised ASI in a 2-year retrospective study between April 2019 and April 2021 in four paediatric intensive care units of a specialist UK children's hospital to quantify antibiotic use based on age, presence of immunosuppression and AMS input. We then compared ASI to days of therapy (DOT) to determine the utility of this AMS metric. We have made changes to Gerber's original ASI list and score of antibiotics to align with prescribing and resistance patterns in the UK. Median ASI/antibiotic days increased with age: for infants under 1 year of age 4.1 (IQR 4.0–4.3), for children 1–5 years 4.4 (IQR 4.0–4.6) and for children over 5 years 4.5 (IQR 4.1–4.6). Immunocompromised patients received much broader-spectrum antibiotics than immunocompetent patients throughout the whole study period. Patients who had AMS input had a higher ASI compared with those who did not throughout the whole period, likely due to more complex patients being discussed on such rounds. Our results show a complex picture of changing antibiotic consumption and prescribing in a large specialist paediatric hospital in the UK with a long-standing AMS programme before and throughout the COVID-19 pandemic. ASI shows less variability than DOT and can potentially be used to identify patient groups and time periods where broader-spectrum antibiotics are used to help guide further AMS efforts. [ABSTRACT FROM AUTHOR]

The incidence of Clostridium difficile infection (CDI) in the UK rose dramatically during the early years of this century, in part associated with the emergence of the hyper-virulent ribotype 027 strain. The University Hospitals of Leicester (UHL), a 2000-bed acute UK NHS Trust, implemented a number of interventions, which led to an 80% reduction in new cases over a twelve month period. Changes were introduced as a result of collaboration between the Infection Prevention team, the departments of Microbiology and Infectious Diseases, and with the support of the Trust Executive. These strategies are described in detail and included; implementation of antimicrobial stewardship, specific hygiene and cleaning measures, the introduction of a care pathway form for all infected patients, the opening of an isolation ward for patients with CDI, strengthened organisation and clinical management, and rigorous attention to education within the Trust. The implementations described are of continued relevance in the face of new infection challenges, such as the increasing incidence of multi-drug resistant organisms. [ABSTRACT FROM AUTHOR]