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ObjectiveTo identify perceptions and awareness of changes in IPC and AMS practices among healthcare workers (HCWs) during the COVID-19 pandemic in India and South Africa (SA).MethodA self-administered online survey which included participant demographics, knowledge and sources of COVID-19 infection, perceived risks and barriers, and self-efficacy. Data were analysed using descriptive statistics.Results321 responses (response rate: 89.2%); 131/321 (40.8%) from India and 190/321 (59.2%) from SA; male to female response rate was 3:2, with majority of respondents aged 40-49 (89/321, 27.7%) and 30-39 (87/321, 27.1%) years. Doctors comprised 47.9% (57/119) of respondents in India and 74.6% (135/181) in SA. Majority of respondents in India (93/119, 78.2%) and SA (132/181, 72.9%) were from the private and public sectors, respectively with more respondents in SA (123/174, 70.7%) than in India (38/104, 36.5%) were involved in antimicrobial prescribing. Respondents reported increased IPC practices since the pandemic and noted need for more training on case management, antibiotic and personal protective equipment (PPE) use. While they noted increased antibiotic prescribing since the pandemic; they did not generally associate their practice with such increase. A willingness to be vaccinated, when vaccination becomes available, was expressed by 203/258 (78.7%) respondents.ConclusionsHCWs reported improved IPC practices and changes in antibiotic prescribing during the COVID-19 pandemic. Targeted education on correct use of PPE was an identified gap. Although HCWs expressed concerns about antimicrobial resistance, their self-perceived antibiotic prescribing practices seemed unchanged. Additional studies in other settings could explore how our findings fit other contexts.KeywordsCOVID-19infection preventioninfection prevention and control (IPC) antimicrobial stewardshiphealthcare workerchange

Objective To explore the existing evidence on patient understanding of and/or participation in infection-related care in surgical specialties. Method A scoping review of the literature was conducted. PubMed, Web of Science, Scopus, and grey literature sources were searched using predefined search criteria for policies, guidelines, and studies in the English language. Data synthesis was done through content and thematic analysis to identify key themes in the included studies. Results The initial search identified 604 studies, of which 41 (36 from high-income and five from low- and middle-income countries) were included in the final review. Most of the included studies focused on measures to engage patients in infection prevention and control (IPC) activities, with few examples of antimicrobial stewardship (AMS) engagement strategies. While patient engagement interventions in infection-related care varied depending on study goals, surgical wound management was the most common intervention. AMS engagement was primarily limited to needs assessment, without follow-up to address such needs. Conclusion Existing evidence highlights a gap in patient participation in infection-related care in the surgical pathway. Standardization of patient engagement strategies is challenging, particularly in the context of surgery, where several factors influence how the patient can engage and retain information. Infection-related patient engagement and participation strategies in surgery need to be inclusive and contextually fit.

We report an empirical analysis of the use of imagery by the key actors in global health who set policy and strategy, and we provide a comprehensive overview, particularly related to images used in reports on vaccination and antimicrobial resistance. The narrative currently depicted in imagery is one of power imbalances, depicting women and children from low-income and middle-income countries (LMICs) with less dignity, respect, and power than those from high-income countries. The absence of any evidence of consent for using intrusive and out-of-context images, particularly of children in LMICs, is concerning. The framework we have developed provides a platform for global health actors to redefine their intentions and recommission appropriate images that are relevant to the topic, respect the integrity of all individuals depicted, are accompanied by evidence of consent, and are equitable in representation. Adhering to these standards will help to avoid inherent biases that lead to insensitive content and misrepresentation, stigmatisation, and racial stereotyping.

A cross-sectional survey was performed among the adult population of participating countries, India and South Africa. The purpose of this study was to explore perceptions and awareness of SARS-CoV-2-related risks in the relevant countries. The main outcome measures were the proportion of participants aware of SARS-CoV-2, and their perception of infection risks.Self-administered questionnaires were used to collect data via a web- and paper-based survey over three months. For data capturing, Microsoft Excel was employed, and descriptive statistics used for presenting data. Pearson’s Chi-squared test was used to assess relationships between variables, and a p-value less than 0.05 was considered significant.There were 844 respondents (India: n=660, South Africa: n=184; response rate 87.6%), with a 61.1% vs 38.3% female to male ratio. Post-high-school or university education was the lowest qualification reported by most respondents in India (77.3%) and South Africa (79.3%). Sources of information about the pandemic were usually media and journal publications (73.2%), social media (64.6%), family and friends (47.7%) and government websites (46.2%). Most respondents correctly identified infection prevention measures (such as physical distancing, mask use), with 90.0% reporting improved hand hygiene practices since the pandemic. Hesitancy or refusal to accept the SARS-CoV-2 vaccine was reported among 17.9% and 50.9% of respondents in India and South Africa, respectively. Reasons cited included rushed vaccine development and the futility of vaccines for what respondents considered a self-limiting flu-like illness.Respondents identified public health promotion measures for SARS-CoV-2. Reported hesitancy to the up-take of SARS-CoV-2 vaccines was much higher in South Africa. Vaccination campaigns should consider robust public engagement and contextually fit communication strategies with multimodal, participatory online and offline initiatives to address public concerns, specifically towards vaccines developed for this pandemic and general vaccine hesitancy.

Introduction\ud Whilst Antimicrobial Stewardship (AMS) is being implemented in different countries, different contexts continue to present unique challenges. We investigated the challenges to implementing AMS in different countries by examining comments from clinical, academic, and lay learners participating in a Massive Open Online Course (MOOC) on tackling antimicrobial resistance (AMR).\ud \ud Methods\ud A 3-week MOOC titled “Tackling AMR: A social science approach” was developed with a global faculty in collaboration with the British Society of Antimicrobial Chemotherapy and Imperial College London and launched in November 2019. Learners were asked specific questions about their experiences of AMS throughout the MOOC which included 38 optional free text prompts. Learners' free text responses from first three-course runs (November 2019 – July 2020) were collated and coded in NVivo 12 using a conventional content analysis approach to identify challenges to implementing AMS across countries. \ud \ud Results\ud Representing 114 countries, 1464 learners enrolled, with largest representation from the United Kingdom, India, Nigeria, Australia, and Pakistan. The learners described a range of AMS activities and team compositions. While recognising the importance of pharmacist and nurse roles in AMS, the learners reported that such roles remain ill-defined across countries, restricting the reach and potential of AMS strategies. A range of challenges to implementing AMS were described, including: limited awareness and engagement by the general public and healthcare workers (HCW) on the impact of AMR on human health, lack of adequate of governance and policy; inconsistencies in surveillance for antibiotic consumption and AMR, impeding feedback loops and improvement processes; human resource and technological constraints; variable access to key antibiotics; lack of ownership of antibiotic decision-making and buy-in from different clinical specialties. Patients’ knowledge, experiences and perspectives were recognised as a valuable source of information that needed to be incorporated in AMS initiatives to overcome cultural barriers to the judicious use of antibiotics. \ud \ud Conclusion\ud Analysis of learner comments and reflections identified a range of enablers and barriers to AMS implementation across different healthcare economies. Common challenges to AMS implementation included the role of non-physician health care professionals, resources, knowledge of AMR and patient engagement and involvement in AMS.

Data sharing: The data used to inform this policy paper can be made able, upon reasonable request from Esmita Charani, e.charani@imperial.ac.uk. Copyright © 2021 The Author(s). Addressing the silent pandemic of antimicrobial resistance (AMR) is a focus of the 2021 G7 meeting. A major driver of AMR and poor clinical outcomes is suboptimal antimicrobial use. Current research in AMR is inequitably focused on new drug development. To achieve antimicrobial security we need to balance AMR research efforts between development of new agents and strategies to preserve the efficacy and maximise effectiveness of existing agents. Combining a review of current evidence and multistage engagement with diverse international stakeholders (including those in healthcare, public health, research, patient advocacy and policy) we identified research priorities for optimising antimicrobial use in humans across four broad themes: policy and strategic planning; medicines management and prescribing systems; technology to optimise prescribing; and context, culture and behaviours. Sustainable progress depends on: developing economic and contextually appropriate interventions; facilitating better use of data and prescribing systems across healthcare settings; supporting appropriate and scalable technological innovation. Implementing this strategy for AMR research on the optimisation of antimicrobial use in humans could contribute to equitable global health security. Wellcome Trust; Economic and Social Research Council (ESRC); National Institute for Health Research ASPIRES project (Antibiotic use across Surgical Pathways: Investigating, Redesigning and Evaluating Systems) (https://www.imperial.ac.uk/arc/aspires/); National Institute for Health Research, UK Department of Health [HPRU-2012-10047] in partnership with Public Health England.

Highlights • Capacity building for research and implementation is key to operationalising global, concerted and sustained strategies for addressing antimicrobial resistance. • Reciprocal and long-term partnerships between high-income and low- and middle-income countries can successfully develop robust, agile, and flexible antimicrobial stewardship research and implementation teams. • Capacity building in AMR when supported by adequate funding to ensure investment in workforce and infrastructure, can result in sustainable and resilient AMS programmes., Research, collaboration and knowledge exchange are critical to global efforts to tackle antimicrobial resistance (AMR). Different healthcare economies are faced with different challenges in implementing effective strategies to address AMR. Building effective capacity for research to inform AMR related strategies and policies AMR is recognised as an important contributor to success. Interdisciplinary, inter-sector, as well as inter-country collaboration is needed to span AMR efforts from the global to local. Developing reciprocal, long-term, partnerships between collaborators in high-income and low- and middle-income countries (LMICs) needs to be built on principles of capacity building. Using case-studies spanning local to international research collaborations to co-design, implement and evaluate strategies to tackle AMR, we evaluate and build upon the ESSENCE criteria for capacity building in LMICs. The first case-study describes the local co-design and implementation of antimicrobial stewardship in the state of Kerala in India. The second case-study describes an international research collaboration investigating AMR across surgical pathways in India, UK and South Africa. We describe the steps undertaken to develop robust, agile, and flexible antimicrobial stewardship research and implementation teams. Notably, investing in capacity building ensured that the programmes described in these case-studies were sustained through the current severe acute respiratory syndrome corona virus pandemic. Describing the strategies adopted by a local and an international collaboration to tackle AMR, we provide a model for capacity building in LMICs that can support sustainable and agile antimicrobial stewardship programmes.

Background The surgical pathway remains a hard to reach, critical target for antimicrobial stewardship (AMS) and infection prevention and control (IPC). We investigated the drivers for surgical AMS and IPC, across cardiovascular and thoracic surgery (CVTS) and gastrointestinal surgery teams in two academic hospitals in South Africa (SA) and India. Materials and methods An ethnographic observational study of IPC and AMS was conducted (July 2018–August 2019), with data gathered from 190 hours of non-participant observations (138 India, 60 SA); face-to-face interviews with patients (6 India, 7 South Africa), and healthcare professionals (HCPs) (44 India, 61 SA); and, in-depth patient case studies (4 India, 2 SA). A grounded theory approach aided by Nvivo 11 software, analyzed the emerging themes. An iterative and recursive process of moving between the coded data and the higher-level themes, ensured saturation of the themes. The multiple modes of enquiry enabled cross-validation and triangulation of findings. Results Across surgical pathways, multiple barriers exist impeding effective IPC and AMS practices. The existing, implicit roles of HCPs (including nurses, and senior surgeons) are overlooked as interventions target junior doctors, bypassing the opportunity for integrating care across the surgical team members. Critically, the ownership of decisions remains with the operating surgeons and entrenched hierarchies restrict the integration of other HCPs in IPC and AMS. Conclusions IPC and AMS are not integrated in surgery. Identifying the implicit existing HCPs roles in IPC and AMS is critical and will facilitate the development of effective and transparent processes across the surgical team for IPC and AMS. Developing a framework approach that includes nurse leadership, empowering pharmacists and engaging surgical leads is essential for integrated care.

Background: Team dynamics influence infection prevention and management practices and implementation of antibiotic stewardship (AS). Using an innovative visual mapping approach, alongside traditional qualitative methods, we aimed to study team dynamics and flow of communication (who gets to speak, and whose voice is heard) during surgical ward rounds, and how team dynamics and communication patterns may shape decision-making in relation to infection management and AS. Materials/methods: Between May and November 2019, data were gathered through direct observations of ward rounds and face-to-face interviews with ward round participants in selected surgical specialties at a tertiary hospital in South Africa. Using a visual mapping method – sociograms – content and flow of communication and the social links between individual participants were plotted. Field notes from observations and interview transcripts were analysed using a grounded theory approach. Results: Data were gathered from 60 hours of ward round observations, including 1024 individual patient discussions; 60 sociograms, interviews with healthcare professionals (60) and patients (7). The nature of discussions about AS and IPC on ward rounds vary across specialties and are affected by the content and structure of the clinical update provided, the consultant’s leadership and interaction style, and competing priorities at the bedside. Registrars act as gatekeepers, initiating antibiotic discussions; consultants are key decision-makers. Other team members have limited input in ward round conversations, despite having recognised roles in AS and IPC. Hierarchies in teams manifest themselves on ward rounds in where staff position themselves, influencing their contribution to care. Varied leadership styles affect ward-round dynamics, in particular, whether nurses and patients are actively engaged in key decisions on infection management and antibiotic therapy, and whether actions are assigned to identified persons. Conclusions: The surgical bedside ward round, though attended by many specialties, remains a medium of communication between registrars and consultants, with little interaction with the patient or other healthcare professionals. A more team-focused and inclusive approach could result in more effective decision making about infection management and AS.

Background: The surgical pathway remains a hard to reach, critical target for antimicrobial stewardship (AMS) and infection prevention and control (IPC) globally. We investigated the drivers for AMS and IPC across surgical teams, in two academic hospitals in South Africa (SA) and India. Methods: Between July 2018 and August 2019, we conducted an ethnographic study across cardiovascular and thoracic surgery (CVTS) and gastrointestinal surgery teams utilizing non-participant observations, face-to-face interviews, and in-depth case-studies. Data were analysed using an inductive-deductive approach, applying thematic framework informed by existing evidence. Observations totalling over 190 hours (138 India, 60 SA) included shadowing healthcare professionals (HCPs) attending daily ward activities and ward rounds. Patients (6 India, 7 South Africa), and HCPs (44 India, 61 SA) were interviewed. Six (4 India, 2 SA) patient case-studies were developed. Findings: Across surgical pathways, multiple steps in IPC and AMS include several key HCPs who have implicit roles. These existing roles of HCPs (including nurses, and senior surgeons) are overlooked as interventions target junior doctors, bypassing the critical roles of the wider range of HCPs. Critically, the ownership of decisions remains with the operating surgeons and entrenched hierarchies restrict the integration of other HCPs in IPC and AMS. Interpretation: IPC and AMS remain key priorities for safe surgery. Identifying the implicit existing roles in AMS and IPC is critical. Developing nurse leadership, empowering pharmacists and engaging surgical leads is essential for integrated care. Many lessons can be learnt from the integrated models of care in the ICU setting. Funding Statement: This study was funded by the Economic and Social Research Council (ESRC) as part of the Antimicrobial Cross Council initiative supported by the seven UK research councils, and the Global Challenges Research Fund (GCRF). Declaration of Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Ethics Approval Statement: Ethics approval for this study was granted by the University of Cape Town Human Research Ethics Committee (HREC ref. 499/2018) and the Amrita Hospital Institutional Research and Ethics Committee (IEC-AIMS-2018-INECONT-005A).