44 results found
Anyanwu P, Costelloe C, Majeed A, et al., Do variations in primary care practice characteristics explain the effect of a financial incentive scheme on antibiotic prescribing? A longitudinal study of the Quality Premium intervention in NHS England, BJGP Open, ISSN: 2398-3795
Honeyford C, Cooke G, Kinderlerer A, et al., 2020, Evaluating a digital sepsis alert in a London multi-site hospital network: a natural experiment using electronic health record data, Journal of the American Medical Informatics Association, Vol: 27, Pages: 274-283, ISSN: 1067-5027
Objective: To determine the impact of a digital sepsis alert on patient outcomes in a UK multi-site hospital network. Methods:A natural experiment utilising the phased introduction (without randomisation) of a digital sepsis alert into a multi-site hospital network. Sepsis alerts were either visible to clinicans (patients in the ‘intervention’ group) or running silently and not visible (the control group). Inverse probability of treatment weighted multivariable logistic regression was used to estimate the effect of the intervention on individual patient outcomes.Outcomes:In-hospital 30-day mortality (all inpatients), prolonged hospital stay (≥7 days) and timely antibiotics (≤60minutes of the alert) for patients who alerted in the Emergency Department. Results: The introduction of the alert was associated with lower odds of death (OR:0.76; 95%CI:(0.70, 0.84) n=21183); lower odds of prolonged hospital stay ≥7 days (OR:0.93; 95%CI:(0.88, 0.99) n=9988); and in patients who required antibiotics, an increased odds of receiving timely antibiotics (OR:1.71; 95%CI:(1.57, 1.87) n=4622).Discussion: Current evidence that digital sepsis alerts are effective is mixed. In this large UK study a digital sepsis alert has been shown to be associated with improved outcomes, including timely antibiotics. It is not known whether the presence of alerting is responsible for improved outcomes, or whether the alert acted as a useful driver for quality improvement initiatives.Conclusions: These findings strongly suggest that the the introduction of a network-wide digital sepsis alert is associated with improvements in patient outcomes, demonstrating that digital based interventions can be successfully introduced and readily evaluated.
Kyaw BM, Car LT, van Galen LS, et al., 2019, Health Professions Digital Education on Antibiotic Management: Systematic Review and Meta-Analysis by the Digital Health Education Collaboration, JOURNAL OF MEDICAL INTERNET RESEARCH, Vol: 21, ISSN: 1438-8871
Anyanwu P, Tonkin-Crine S, Borek A, et al., 2019, Investigating the mechanism of impact of the quality premium initiative on antibiotic prescribing in primary care practices in England: a study protocol, BMJ Open, Vol: 9, ISSN: 2044-6055
IntroductionThe persistent development and spread of resistance to antibiotics remains an important public health concern in the UK and globally. About 74% of antibiotics prescribed in England in 2016 was in primary care. The Quality Premium (QP) initiative that rewards Clinical Commissioning Groups (CCGs) financially based on the quality of specific health services commissioned is one of the National Health Service (NHS) England interventions to reduce antimicrobial resistance through reduced prescribing. Emerging evidence suggests a reduction in antibiotic prescribing in primary care practices in the UK following QP initiative. This study aims to investigate the mechanism of impact of this high-cost health-system level intervention on antibiotic prescribing in primary care practices in England.Methods and analysisThe study will constitute secondary analyses of antibiotic prescribing data for almost all primary care practices in England from the NHS England Antibiotic Quality Premium Monitoring Dashboard and OpenPrescribing covering the period 2013 to 2018. The primary outcome is the number of antibiotic items per Specific Therapeutic group Age-sex Related Prescribing Unit (STAR-PU) prescribed monthly in each practice or CCG. We will first conduct an interrupted time series using Ordinary Least Square regression method to examine whether antibiotic prescribing rate in England has changed over time, and how such changes, if any, are associated with QP implementation. Single and sequential multiple-mediator models using a unified approach for the natural direct and indirect effects will be conducted to investigate the relationship between QP initiative, the potential mediators and antibiotic prescribing rate with adjustment for practice and CCG characteristics.Ethics and disseminationThis study will use secondary data that are anonymised and obtained from studies that have either undergone ethical review or generated data from routine collection systems. Multiple cha
Saxena S, Skirrow H, Wincott T, et al., 2019, Preschool respiratory hospital admissions following infant bronchiolitis: a birth cohort study, Archives of Disease in Childhood, Vol: 104, Pages: 658-663, ISSN: 1468-2044
Background: Bronchiolitis causes significant infant morbidity worldwide from hospital admissions. However, studies quantifying the subsequent respiratory burden in children under 5 years are lacking.Objective: To estimate the risk of subsequent respiratory hospital admissions in children under 5 years in England following bronchiolitis admission in infancy.Design: Retrospective population-based birth cohort study.Setting: Public hospitals in England.Patients: We constructed a birth cohort of 613,377 infants born between 1.4.2007 and 31.3.2008, followed up until aged 5 years by linking Hospital Episode Statistics (HES) admissions data. Methods: We compared the risk of respiratory hospital admission due to asthma, wheezing and lower and upper respiratory tract infections(LRTI & URTI) in infants who had been admitted for bronchiolitis with those who had not, using Cox proportional hazard regression. We adjusted hazard ratios for known respiratory illness risk factors including living in deprived households, being born preterm or with a comorbid condition.Results: We identified 16,288/613,377 infants(2.7 %) with at least one admission for bronchiolitis. Of these, 21.7% had a further respiratory hospital admission by age 5 years compared with 8% without a previous bronchiolitis admission, (HR(adjusted),2.82, 95%CI 2.72-2.92). The association was greatest for asthma (HR(adjusted), 4.35, 95%CI 4.00-4.73) and wheezing admissions (HR(adjusted), 5.02, 95%CI 4.64-5.44) but were also significant for URTI and LRTI admissions. Conclusions: Hospital admission for bronchiolitis in infancy is associated with a 3-to-5-fold risk of subsequent respiratory hospital admissions from asthma, wheezing and respiratory infections. One in five infants with bronchiolitis hospital admissions will have a subsequent respiratory hospital admission by age 5 years.
Aylin PP, Bou-Antoun S, Costelloe CE, et al., 2018, Age-related decline in antibiotic prescribing for uncomplicated respiratory tract infections in primary care in England following the introduction of a national financial incentive (the Quality Premium) for health commissioners to reduce use of antibiotics in the community: an interrupted time series analysis, Journal of Antimicrobial Chemotherapy, Vol: 73, Pages: 2883-2892, ISSN: 0305-7453
Objectives: To assess the impact of the 2015/16 NHS England Quality Premium (which provided a financial incentive for Clinical Commissioning Groups to reduce antibiotic prescribing in primary care) on antibiotic prescribing by General Practitioners (GPs) for respiratory tract infections (RTIs).Method: Interrupted time series analysis using monthly patient-level consultation and prescribing data obtained from the Clinical Practice Research Datalink (CPRD), between April 2011 and March 2017. The study population comprised patients consulting a GP who were diagnosed with an RTI. We assessed the rate of antibiotic prescribing in patients (both aggregate and stratified by age) with a recorded diagnosis of uncomplicated RTI, before and after the implementation of the Quality Premium.Results: Prescribing rates decreased over the six year study period, with evident seasonality. Notably, there was a 3% drop in the rate of antibiotic prescribing (equating to 14.65 prescriptions per 1,000 RTI consultations) (p<0.05) in April 2015, coinciding with the introduction of the Quality Premium. This reduction was sustained, such that after two years there was a 3% decrease in prescribing relative to that expected had the pre-intervention trend continued. There was also a concurrent 2% relative reduction in the rate of broad-spectrum antibiotic prescribing. Antibiotic prescribing for RTIs diagnosed in children showed the greatest decline with a 6% relative change two years after the intervention. Of the RTI indications studied, the greatest reductions in antibiotic prescribing were seen for patients with sore throats.Conclusions: Community prescribing of antibiotics for RTIs significantly decreased following the introduction of the Quality Premium, with the greatest reduction seen in younger patients.
Lishman H, Costelloe C, Hopkins S, et al., Exploring the relationship between primary care antibiotic prescribing for urinary tract infections, Escherichia coli bacteraemia incidence and antibiotic resistance: an ecological study, International Journal of Antimicrobial Agents, ISSN: 0924-8579
Knight GM, Costelloe C, Deeny S, et al., 2018, Quantifying where human acquisition of antibiotic resistance occurs: a mathematical modelling study, BMC Medicine, Vol: 16, ISSN: 1741-7015
BackgroundAntibiotic-resistant bacteria (ARB) are selected by the use of antibiotics. The rational design of interventions to reduce levels of antibiotic resistance requires a greater understanding of how and where ARB are acquired. Our aim was to determine whether acquisition of ARB occurs more often in the community or hospital setting.MethodsWe used a mathematical model of the natural history of ARB to estimate how many ARB were acquired in each of these two environments, as well as to determine key parameters for further investigation. To do this, we explored a range of realistic parameter combinations and considered a case study of parameters for an important subset of resistant strains in England.ResultsIf we consider all people with ARB in the total population (community and hospital), the majority, under most clinically derived parameter combinations, acquired their resistance in the community, despite higher levels of antibiotic use and transmission of ARB in the hospital. However, if we focus on just the hospital population, under most parameter combinations a greater proportion of this population acquired ARB in the hospital.ConclusionsIt is likely that the majority of ARB are being acquired in the community, suggesting that efforts to reduce overall ARB carriage should focus on reducing antibiotic usage and transmission in the community setting. However, our framework highlights the need for better pathogen-specific data on antibiotic exposure, ARB clearance and transmission parameters, as well as the link between carriage of ARB and health impact. This is important to determine whether interventions should target total ARB carriage or hospital-acquired ARB carriage, as the latter often dominated in hospital populations.
Bryce A, Costelloe CE, wooten A, et al., 2018, Comparison of risk factors for, and prevalence of, antibiotic resistance in contaminating and pathogenic urinary Escherichia coli in children in primary care: prospective cohort study, Journal of Antimicrobial Chemotherapy, Vol: 73, Pages: 1359-1367, ISSN: 0305-7453
BackgroundAll-cause antibiotic prescribing affects bowel flora antimicrobial susceptibility, and may increase risk of urinary autoinoculation with antibiotic-resistant microbes. However, little is known about relative prevalence of, or risk factors for, antimicrobial resistance among potentially pathogenic microbes thought to be contaminating and infecting urine.MethodsSecondary analysis of 824 children under 5 years of age consulting in primary care for an acute illness and their Escherichia coli isolates cultured at ≥103 cfu/mL from the Diagnosis of Urinary Tract infection in Young children (DUTY) study. Multivariable logistic regression investigating risk factors for resistance to amoxicillin, co-amoxiclav, cefalexin, ciprofloxacin, trimethoprim, nitrofurantoin and cefpodoxime in microbes meeting the laboratory criteria for urinary tract infection: ‘pathogens’ (>105 cfu/mL, n = 79) and ‘contaminants’ (103 to 105 cfu/mL, n = 745).ResultsForty-three percent of E. coli were resistant to at least one tested antibiotic, with resistance highest to amoxicillin (49.37% pathogenic versus 37.32% contaminant, P = 0.04), trimethoprim (27.85% versus 16.52%, P = 0.01) and co-amoxiclav (16.46% versus 21.48%, P = 0.30). Multidrug resistance (to ≥3 antibiotic groups) was present in 17.07% of pathogens and 30.13% of contaminants (P = 0.04). No isolates were resistant to nitrofurantoin. Recent (0–3 months) exposure to antibiotics was associated with resistance in both pathogens (aOR: 1.10, 95% CI: 1.01–4.39) and contaminants (1.69, 1.09–2.67).ConclusionsPrevalence of resistance (including multidrug) was high, but there was no consistent relationship between isolate pathogen/contamination status and resistance. Recent all-cause antibiotic prescribing increased the probability of antimicrobial resistance in both pathogenic and contaminat
Lishman H, Aylin P, Alividza V, et al., 2017, Investigating the burden of antibiotic resistance in ethnic minority groups in high-income countries: protocol for a systematic review and meta-analysis., Systematic Reviews, Vol: 6, ISSN: 2046-4053
Background: Antibiotic resistance (ABR) is an urgent problem globally, with overuse and misuse of antibioticsbeing one of the main drivers of antibiotic-resistant infections. There is increasing evidence that the burden ofcommunity-acquired infections such as urinary tract infections and bloodstream infections (both susceptible andresistant) may differ by ethnicity, although the reasons behind this relationship are not well defined. It has beendemonstrated that socioeconomic status and ethnicity are often highly correlated with each other; however, it isnot yet known whether accounting for deprivation completely explains any discrepancy seen in infection risk. Therehave currently been no systematic reviews summarising the evidence for the relationship between ethnicity andantibiotic resistance or prescribing.Methods: This protocol will outline how we will conduct this systematic literature review and meta-analysisinvestigating whether there is an association between patient ethnicity and (1) risk of antibiotic-resistant infectionsor (2) levels of antibiotic prescribing in high-income countries. We will search PubMed/MEDLINE, EMBASE, GlobalHealth, Scopus and CINAHL using MESH terms where applicable. Two reviewers will conduct title/abstract screening,data extraction and quality assessment independently. The Critical Appraisal Skills Programme (CASP) checklist will beused for cohort and case-control studies, and the Cochrane collaboration’s risk of bias tool will be used for randomisedcontrol trials, if they are included. Meta-analyses will be performed by calculating the minority ethnic group to majorityethnic group odds ratios or risk ratios for each study and presenting an overall pooled odds ratio for the two outcomes.The Grading of Recommendations, Assessments, Development and Evaluation (GRADE) approach will be used to assessthe overall quality of the body of evidence.Discussion: In this systematic review and meta-analysis, we will aim to collate the avail
Costelloe C, 2017, English surveillance programme for antimicrobial utilisation and resistance (ESPAUR)Report 2017
Background: Antimicrobial resistance (AMR) is one of greatest problems facing modern medicine. In 2014, the advisory committee on Antimicrobial Resistance and Healthcare- Associated Infection (ARHAI) devised Antibiotic Prescribing Quality Measures (APQM) to curb unnecessary overuse of antibiotics and combat AMR in England. These measures were implemented in April 2015 in the form of a quality premium (QP) awarded to clinical commissioning groups (CCG) for reducing antibiotic prescriptions in primary care.Objectives: To examine trends in children's syrup antibiotic prescribing in general practitioners’ (GP) practices over time across English CCGs and establish if they have changed post-introduction of the 2015-16 APQMs. To compare prescriptions in CCG that did or did not meet the requirements of the QP.Methods: Retrospective cross-sectional study using data from Public Health England detailing syrup antibiotic prescriptions for respiratory tract infections and urinary tract infections from GP practices across England.Findings and interpretation: The study is currently in the analysis phase. Findings from this study could quantify the effect of an AMS intervention, the Antibiotic Prescribing Quality Measures on antibiotic prescribing at the GP practice and at CCG level over time. The study could also serve to provide evidence to support the adoption of and compliance with AMS Programmes in CCGs across England.
Knight GM, Costelloe C, Murray KA, et al., 2017, Addressing the unknowns of antimicrobial resistance: quantifying and mapping the drivers of burden, Clinical Infectious Diseases, Vol: 66, Pages: 612-616, ISSN: 1058-4838
The global threat of antimicrobial resistance (AMR) has arisen through a network of complex interacting factors. Many different sources and transmission pathways contribute to the ever-growing burden of AMR in our clinical settings. The lack of data on these mechanisms and the relative importance of different factors causing the emergence and spread of AMR hampers our global efforts to effectively manage the risks. Importantly, we have little quantitative knowledge on the relative contributions of these sources and are likely to be targeting our interventions suboptimally as a result. Here we propose a systems mapping approach to address the urgent need for reliable and timely data in order to strengthen the response to AMR.
Banerjee K, Mathie RT, Costelloe C, et al., 2017, Homeopathy for Allergic Rhinitis: A Systematic Review, Journal of Alternative and Complementary Medicine, Vol: 23, Pages: 426-444, ISSN: 1075-5535
Objective: The aim of this study was to evaluate the efficacy and effectiveness of homeopathic intervention inthe treatment of seasonal or perennial allergic rhinitis (AR).Method: Randomized controlled trials evaluating all forms of homeopathic treatment for AR were includedin a systematic review (SR) of studies published up to and including December 2015. Two authors independentlyscreened potential studies, extracted data, and assessed risk of bias. Primary outcomes included symptomimprovement and total quality-of-life score. Treatment effect size was quantified as mean difference (continuousdata), or by risk ratio (RR) and odds ratio (dichotomous data), with 95% confidence intervals (CI). Metaanalysiswas performed after assessing heterogeneity and risk of bias.Results: Eleven studies were eligible for SR. All trials were placebo-controlled except one. Six trials used thetreatment approach known as isopathy, but they were unsuitable for meta-analysis due to problems of heterogeneityand data extraction. The overall standard of methods and reporting was poor: 8/11 trials wereassessed as ‘‘high risk of bias’’; only one trial, on isopathy for seasonal AR, possessed reliable evidence. Threetrials of variable quality (all using Galphimia glauca for seasonal AR) were included in the meta-analysis: nasalsymptom relief at 2 and 4 weeks (RR= 1.48 [95% CI 1.24–1.77] and 1.27 [95% CI 1.10–1.46], respectively)favored homeopathy compared with placebo; ocular symptom relief at 2 and 4 weeks also favored homeopathy(RR= 1.55 [95% CI 1.33–1.80] and 1.37 [95% CI 1.21–1.56], respectively). The single trial with reliableevidence had a small positive treatment effect without statistical significance. A homeopathic and a conventionalnasal spray produced equivalent improvements in nasal and ocular symptoms.Conclusions: The low or uncertain overall quality of the evidence warrants caution in drawing firm conclusionsabout intervention effects.
Holmes AH, Boyd SE, Moore LSP, et al., 2017, Obtaining antibiotics online from within the UK: a cross-sectional study, Journal of Antimicrobial Chemotherapy, ISSN: 1460-2091
Lishman H, Castro Sanchez EM, Charani E, et al., 2016, The burden of antimicrobial-resistant infections in black and minority ethnic groups, The burden of antimicrobial-resistant infections in black and minority ethnic groups
Lishman H, Charani E, Castro Sanchez E, et al., 2016, The burden of antimicrobial-resistant infections in black and minority ethnic groups, Better Health Briefing
In this briefing, the NIHR Health Protection Research Unit in Healthcare-Associated Infections and Antimicrobial Resistance will explore the evidence base to identify areas where practice could be improved to ensure that all service users are equally aware of the drivers of AMR infections. Countering this global threat cannot be done without the awareness, prudence and participation of all members of society, from healthcare providers to politicians to patients.
Bryce A, Costelloe C, Hawcroft C, et al., 2016, Faecal carriage of antibiotic resistant Escherichia coli in asymptomatic children and associations with primary care antibiotic prescribing: a systematic review and meta-analysis, BMC Infectious Diseases, Vol: 16, ISSN: 1471-2334
BackgroundThe faecal reservoir provides optimal conditions for the transmission of resistance genes within and between bacterial species. As key transmitters of infection within communities, children are likely important contributors to endemic community resistance. We sought to determine the prevalence of antibiotic-resistant faecal Escherichia coli from asymptomatic children aged between 0 and 17 years worldwide, and investigate the impact of routinely prescribed primary care antibiotics to that resistance.MethodsA systematic search of Medline, Embase, Cochrane and Web of Knowledge databases from 1940 to 2015. Pooled resistance prevalence for common primary care antibiotics, stratified by study country OECD status. Random-effects meta-analysis to explore the association between antibiotic exposure and resistance.ResultsThirty-four studies were included. In OECD countries, the pooled resistance prevalence to tetracycline was 37.7 % (95 % CI: 25.9–49.7 %); ampicillin 37.6 % (24.9–54.3 %); and trimethoprim 28.6 % (2.2–71.0 %). Resistance in non-OECD countries was uniformly higher: tetracycline 80.0 % (59.7–95.3 %); ampicillin 67.2 % (45.8–84.9 %); and trimethoprim 81.3 % (40.4–100 %). We found evidence of an association between primary care prescribed antibiotics and resistance lasting for up to 3 months post-prescribing (pooled OR: 1.65, 1.36–2.0).ConclusionsResistance to many primary care prescribed antibiotics is common among faecal E. coli carried by asymptomatic children, with higher resistance rates in non-OECD countries. Despite tetracycline being contra-indicated in children, tetracycline resistance rates were high suggesting children could be important recipients and transmitters of resistant bacteria, or that use of other antibiotics is leading to tetracycline resistance via inter-bacteria resistance transmission.
Micallef C, Mcleod M, Castro Sanchez EM, et al., 2016, An Evidence-Based Antimicrobial Stewardship Smartphone App for Hospital Outpatients: Survey-based Needs Assessment Among Patients, Journal of Medical Internet Research, Vol: 4, ISSN: 1439-4456
Background: Current advances in modern technology have enabled the development and utilization of electronic medicalsoftware apps for both mobile and desktop computing devices. A range of apps on a large variety of clinical conditions for patientsand the public are available, but very few target antimicrobials or infections.Objective: We sought to explore the use of different antimicrobial information resources with a focus on electronic platforms,including apps for portable devices, by outpatients at two large, geographically distinct National Health Service (NHS) teachinghospital trusts in England. We wanted to determine whether there is demand for an evidence-based app for patients, to garnertheir perceptions around infections/antimicrobial prescribing, and to describe patients’ experiences of their interactions withhealth care professionals in relation to this topic.Methods: A cross-sectional survey design was used to investigate aspects of antimicrobial prescribing and electronic devicesexperienced by patients at four hospitals in London and a teaching hospital in the East of England.Results: A total of 99 surveys were completed and analyzed. A total of 82% (80/98) of respondents had recently been prescribedantimicrobials; 87% (85/98) of respondents were prescribed an antimicrobial by a hospital doctor or through their generalpractitioner (GP) in primary care. Respondents wanted information on the etiology (42/65, 65%) and prevention and/or management(32/65, 49%) of their infections, with the infections reported being upper and lower respiratory tract, urinary tract, oral, and skinand soft tissue infections. All patients (92/92, 100%) desired specific information on the antimicrobial prescribed. Approximatelyhalf (52/95, 55%) stated it was “fine” for doctors to use a mobile phone/tablet computer during the consultation while 13% (12/95)did not support the idea of doctors accessing health care information in this way. Although only 30% (27/89)
Eldridge SM, Costelloe CE, Kahan BC, et al., 2016, How big should the pilot study for my cluster randomised trial be?, STATISTICAL METHODS IN MEDICAL RESEARCH, Vol: 25, Pages: 1039-1056, ISSN: 0962-2802
Barnes TR, Leeson VC, Paton C, et al., 2016, Antidepressant Controlled Trial For Negative Symptoms In Schizophrenia (ACTIONS): a double-blind, placebo-controlled, randomised clinical trial, Health Technology Assessment, Vol: 20, ISSN: 1366-5278
BACKGROUND: Negative symptoms of schizophrenia represent deficiencies in emotional responsiveness, motivation, socialisation, speech and movement. When persistent, they are held to account for much of the poor functional outcomes associated with schizophrenia. There are currently no approved pharmacological treatments. While the available evidence suggests that a combination of antipsychotic and antidepressant medication may be effective in treating negative symptoms, it is too limited to allow any firm conclusions. OBJECTIVE: To establish the clinical effectiveness and cost-effectiveness of augmentation of antipsychotic medication with the antidepressant citalopram for the management of negative symptoms in schizophrenia. DESIGN: A multicentre, double-blind, individually randomised, placebo-controlled trial with 12-month follow-up. SETTING: Adult psychiatric services, treating people with schizophrenia. PARTICIPANTS: Inpatients or outpatients with schizophrenia, on continuing, stable antipsychotic medication, with persistent negative symptoms at a criterion level of severity. INTERVENTIONS: Eligible participants were randomised 1 : 1 to treatment with either placebo (one capsule) or 20 mg of citalopram per day for 48 weeks, with the clinical option at 4 weeks to increase the daily dosage to 40 mg of citalopram or two placebo capsules for the remainder of the study. MAIN OUTCOME MEASURES: The primary outcomes were quality of life measured at 12 and 48 weeks assessed using the Heinrich's Quality of Life Scale, and negative symptoms at 12 weeks measured on the negative symptom subscale of the Positive and Negative Syndrome Scale. RESULTS: No therapeutic benefit in terms of improvement in quality of life or negative symptoms was detected for citalopram over 12 weeks or at 48 weeks, but secondary analysis suggested modest improvement in the negative symptom domain, avolition/amotivation, at 12 weeks (mean difference -1.3, 95% confidence inter
Bryce A, Hay AD, Lane IF, et al., 2016, Global prevalence of antibiotic resistance in paediatric urinary tract infections caused by Escherichia coli and association with routine use of antibiotics in primary care: systematic review and meta-analysis, British Medical Journal, Vol: 352, ISSN: 1468-5833
Objectives To systematically review studies investigating the prevalence of antibiotic resistance in urinary tract infections caused by Escherichia coli in children and, when appropriate, to meta-analyse the relation between previous antibiotics prescribed in primary care and resistance.Design and data analysis Systematic review and meta-analysis. Pooled percentage prevalence of resistance to the most commonly used antibiotics in children in primary care, stratified by the OECD (Organisation for Economic Co-operation and Development) status of the study country. Random effects meta-analysis was used to quantify the association between previous exposure to antibiotics in primary care and resistance.Data sources Observational and experimental studies identified through Medline, Embase, Cochrane, and ISI Web of Knowledge databases, searched for articles published up to October 2015.Eligibility criteria for selecting studies Studies were eligible if they investigated and reported resistance in community acquired urinary tract infection in children and young people aged 0-17. Electronic searches with MeSH terms and text words identified 3115 papers. Two independent reviewers assessed study quality and performed data extraction.Results 58 observational studies investigated 77 783 E coli isolates in urine. In studies from OECD countries, the pooled prevalence of resistance was 53.4% (95% confidence interval 46.0% to 60.8%) for ampicillin, 23.6% (13.9% to 32.3%) for trimethoprim, 8.2% (7.9% to 9.6%) for co-amoxiclav, and 2.1% (0.8 to 4.4%) for ciprofloxacin; nitrofurantoin was the lowest at 1.3% (0.8% to 1.7%). Resistance in studies in countries outside the OECD was significantly higher: 79.8% (73.0% to 87.7%) for ampicillin, 60.3% (40.9% to 79.0%) for co-amoxiclav, 26.8% (11.1% to 43.0%) for ciprofloxacin, and 17.0% (9.8% to 24.2%) for nitrofurantoin. There was evidence that bacterial isolates from the urinary tract from individual children who had received previous
Stansfeld SA, Kerry S, Chandola T, et al., 2015, Pilot study of a cluster randomised trial of a guided e-learning health promotion intervention for managers based on management standards for the improvement of employee well-being and reduction of sickness absence: GEM Study, BMJ Open, Vol: 5, ISSN: 2044-6055
Objectives To investigate the feasibility of recruitment, adherence and likely effectiveness of an e-learning intervention for managers to improve employees’ well-being and reduce sickness absence.Methods The GEM Study (guided e-learning for managers) was a mixed methods pilot cluster randomised trial. Employees were recruited from four mental health services prior to randomising three services to the intervention and one to no-intervention control. Intervention managers received a facilitated e-learning programme on work-related stress. Main outcomes were Warwick Edinburgh Mental Wellbeing Scale (WEMWBS), 12-item GHQ and sickness absence <21 days from human resources. 35 in-depth interviews were undertaken with key informants, managers and employees, and additional observational data collected.Results 424 of 649 (65%) employees approached consented, of whom 350 provided WEMWBS at baseline and 284 at follow-up; 41 managers out of 49 were recruited from the three intervention clusters and 21 adhered to the intervention. WEMWBS scores fell from 50.4–49.0 in the control (n=59) and 51.0–49.9 in the intervention (n=225), giving an intervention effect of 0.5 (95% CI −3.2 to 4.2). 120/225 intervention employees had a manager who was adherent to the intervention. HR data on sickness absence (n=393) showed no evidence of effect. There were no effects on GHQ score or work characteristics. Online quiz knowledge scores increased across the study in adherent managers. Qualitative data provided a rich picture of the context within which the intervention took place and managers’ and employees’ experiences of it.Conclusions A small benefit from the intervention on well-being was explained by the mixed methods approach, implicating a low intervention uptake by managers and suggesting that education alone may be insufficient. A full trial of the guided e-learning intervention and economic evaluation is feasible. Future research should include mo
Stansfeld SA, Berney L, Bhui K, et al., 2015, Pilot study of a randomised trial of a guided e-learning health promotion intervention for managers based on management standards for the improvement of employee well-being and reduction of sickness absence: the GEM (Guided E-learning for Managers) study, Public Health Research, Vol: 3, Pages: 1-114, ISSN: 2050-4381
Background:Psychosocial work environments influence employee well-being. There is a need for an evaluation of organisational-level interventions to modify psychosocial working conditions and hence employee well-being.Objective:To test the acceptability of the trial and the intervention, the feasibility of recruitment and adherence to and likely effectiveness of the intervention within separate clusters of an organisation.Design:Mixed methods: pilot cluster randomised controlled trial and qualitative study (in-depth interviews, focus group and observation).Participants:Employees and managers of a NHS trust. Inclusion criteria were the availability of sickness absence data and work internet access. Employees on long-term sick leave and short-term contracts and those with a notified pregnancy were excluded.Intervention:E-learning program for managers based on management standards over 10 weeks, guided by a facilitator and accompanied by face-to-face meetings. Three clusters were randomly allocated to receive the guided e-learning intervention; a fourth cluster acted as a control.Main outcome measures:Recruitment and participation of employees and managers; acceptability of the intervention and trial; employee subjective well-being using the Warwick–Edinburgh Mental Wellbeing Scale (WEMWBS); and feasibility of collecting sickness absence data.Results:In total, 424 employees out of 649 approached were recruited and 41 managers out of 49 were recruited from the three intervention clusters. Of those consenting, 350 [83%, 95% confidence interval (CI) 79% to 86%] employees completed the baseline assessment and 291 (69%, 95% CI 64% to 73%) completed the follow-up questionnaires. Sickness absence data were available from human resources for 393 (93%, 95% CI 90% to 95%) consenting employees. In total, 21 managers adhered to the intervention, completing at least three of the six modules. WEMWBS scores fell slightly in all groups, from 50.4 to 49.0 in the control group and
Loopstra R, Reeves A, Taylor-Robinson D, et al., 2015, Austerity, sanctions, and the rise of food banks in the UK, BMJ, Vol: 350, Pages: h1775-h1775, ISSN: 0959-8138
Lokhmatkina NV, Agnew-Davies R, Costelloe C, et al., 2015, Intimate partner violence and ways of coping with stress: cross-sectional survey of female patients in Russian general practice, Family Practice, Vol: 32, Pages: 141-146, ISSN: 0263-2136
Nicholson AL, Campbell RM, Brookes ST, et al., 2014, HAND HYGIENE AND ABSENTEEISM IN PRIMARY SCHOOLS; A CLUSTER RANDOMISED CONTROLLED TRIAL, Publisher: BMJ PUBLISHING GROUP, Pages: A14-A14, ISSN: 0143-005X
Banerjee K, Costelloe C, Mathie RT, et al., 2014, Homeopathy for allergic rhinitis: protocol for a systematic review., Syst Rev, Vol: 3
BACKGROUND: Allergic rhinitis is a global health problem that is often treated with homeopathy. The objective of this review will be to evaluate the effectiveness of homeopathic treatment of allergic rhinitis. METHODS/DESIGN: The authors will conduct a systematic review. We will search Medline, CENTRAL, CINAHL, EMBASE, AMED, CAM-Quest, Google Scholar and reference lists of identified studies up to December 2013.The review will include randomized controlled trials that evaluate homeopathic treatment of allergic rhinitis. Studies with participants of all ages, with acute or chronic comorbidities will be included. Patients with immunodeficiency will not be included. The diagnosis will be based on the published guidelines of diagnosis and classification. Studies of all homeopathy modalities (clinical, complex and classical homeopathy, and isopathy) will be included. We will include trials with both active controls (conventional therapy, standard care) and placebo controls.The primary outcomes are: an improvement of global symptoms recorded in validated daily or weekly diaries and any scores from validated visual analogue scales; the total Quality of Life Score (such as the Juniper RQLQ);individual symptoms scores which include any appropriate measures of nasal obstruction, runny nose, sneezing, itching, and eye symptoms; and number of days requiring medication. Secondary outcomes selected will include serum immunoglobin E (IgE) levels, individual ocular symptoms, adverse events, and the use of rescue medication.Treatment effects will be measured by calculating the mean difference and the standardized mean difference with 95% confidence interval (CI) for continuous data. Risk ratio or, if feasible, odds ratio will be calculated with 95% CI for dichotomous data. After assessing clinical and statistical heterogeneity, meta-analysis will be performed, if appropriate. The individual participant will be the unit of analysis. Descriptive information on missing data will be inc
Costelloe C, Williams O, Montgomery A, et al., 2014, Antibiotic prescribing in primary care and antimicrobial resistance in patients admitted to hospital with urinary tract infection: a controlled observational pilot study, Antibiotics, Vol: 3, Pages: 29-38, ISSN: 2079-6382
There is growing evidence that primary care prescribed antibiotics lead to antibiotic resistance in bacteria causing minor infections or being carried by asymptomatic adults, but little research to date has investigated links between primary care prescribed antibiotics and resistance among more serious infections requiring hospital care. Knowledge of these effects is likely to have a major influence on public expectations for, and primary care use of, antibiotics. This study aimed to assess the feasibility of recruiting symptomatic adult patients admitted to hospital with urinary infections and to link primary and secondary data information to investigate the relationship between primary care prescribed antibiotics and antimicrobial resistance in these patients. A microbiology database search of in patients who had submitted a urine sample identified 740 patients who were potentially eligible to take part in the study. Of these, 262 patients did not meet the eligibility criteria, mainly due to use of a urinary catheter (40%). Two-hundred and forty three patients could not be recruited as the nurse was unable to visit the patients prior to discharge, as they were too unwell. Eighty patients provided complete information. Results indicate that there is evidence that prior antibiotic use is associated with resistant infections in hospital patients. A fully powered study, conducted using routinely collected data is proposed to fully clarify the precision of the association.
Redmond NM, Hollinghurst S, Costelloe C, et al., 2013, An evaluation of the impact and costs of three strategies used to recruit acutely unwell young children to a randomised controlled trial in primary care., Clin Trials, Vol: 10, Pages: 593-603
BACKGROUND: Recruitment to primary care trials, particularly those involving young children, is known to be difficult. There are limited data available to inform researchers about the effectiveness of different trial recruitment strategies and their associated costs. PURPOSE: To describe, evaluate, and investigate the costs of three strategies for recruiting febrile children to a community-based randomised trial of antipyretics. METHODS: The three recruitment strategies used in the trial were termed as follows: (1) 'local', where paediatric research nurses stationed in primary care sites invited parents of children to participate; (2) 'remote', where clinicians at primary care sites faxed details of potentially eligible children to the trial office; and (3) 'community', where parents, responding to trial publicity, directly contacted the trial office when their child was unwell. RESULTS: Recruitment rates increased in response to the sequential introduction of three recruitment strategies, which were supplemented by additional recruiting staff, flexible staff work patterns, and improved clinician reimbursement schemes. The three strategies yielded different randomisation rates. They also appeared to be interdependent and highly effective together. Strategy-specific costs varied from £297 to £857 per randomised participant and represented approximately 10% of the total trial budget. LIMITATIONS: Because the recruitment strategies were implemented sequentially, it was difficult to measure their independent effects. The cost analysis was performed retrospectively. CONCLUSIONS: Trial recruiter expertise and deployment of several interdependent, illness-specific strategies were key factors in achieving rapid recruitment of young children to a community-based randomised controlled trial (RCT). The 'remote' recruitment strategy was shown to be more cost-effective compared to 'community' and 'local' strategies in the context of this trial. Future trialists shoul
Chalder M, Wiles NJ, Campbell J, et al., 2013, Republished research: Facilitated physical activity as a treatment for depressed adults: randomised controlled trial:, British Journal of Sports Medicine, Vol: 47, Pages: 629-629, ISSN: 0306-3674
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