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  • Journal article
    Charani E, Smith I, Skodvin B, Perozziello A, Lucet JC, Lescure FX, Brigand G, Poda A, Ahmad R, Singh S, Holmes AHet al., 2019,

    Investigating the cultural and contextual determinants of antimicrobial stewardship programmes across low-, middle- and high-income countries – a qualitative study

    , PLoS ONE, Vol: 14, ISSN: 1932-6203

    BackgroundMost of the evidence on antimicrobial stewardship programmes (ASP) to help sustain the effectiveness of antimicrobials is generated in high income countries. We report a study investigating implementation of ASP in secondary care across low-, middle- and high-income countries. The objective of this study was to map the key contextual, including cultural, drivers of the development and implementation of ASP across different resource settings.Materials and methodsHealthcare professionals responsible for implementing ASP in hospitals in England, France, Norway, India, and Burkina Faso were invited to participate in face-to face interviews. Field notes from observations, documentary evidence, and interview transcripts were analysed using grounded theory approach. The key emerging categories were analysed iteratively using constant comparison, initial coding, going back the field for further data collection, and focused coding. Theoretical sampling was applied until the categories were saturated. Cross-validation and triangulation of the findings were achieved through the multiple data sources.Results54 participants from 24 hospitals (England 9 participants/4 hospitals; Norway 13 participants/4 hospitals; France 9 participants/7 hospitals; India 13 participants/ 7 hospitals; Burkina Faso 8 participants/2 hospitals) were interviewed. Across Norway, France and England there was consistency in ASP structures. In India and Burkina Faso there were country level heterogeneity in ASP. State support for ASP was perceived as essential in countries where it is lacking (India, Burkina Faso), and where it was present, it was perceived as a barrier (England, France). Professional boundaries are one of the key cultural determinants dictating involvement in initiatives with doctors recognised as leaders in ASP. Nurse and pharmacist involvement was limited to England. The surgical specialty was identified as most difficult to engage with in each country. Despite challenges, on

  • Journal article
    Troughton R, Birgand G, Johnson AP, Naylor N, Gharbi M, Aylin P, Hopkins S, Jaffer U, Holmes Aet al., 2018,

    Mapping national surveillance of surgical site infections (SSIs) to national needs and priorities: an assessment of England’s surveillance landscape

    , Journal of Hospital Infection, Vol: 100, Pages: 378-385, ISSN: 0195-6701

    BackgroundThe rise in antimicrobial resistance has highlighted the importance of surgical site infection (SSI) prevention with effective surveillance strategies playing a key role in improving patient safety. This study maps national needs and priorities for SSI surveillance against current national surveillance activity.MethodsThis study analysed SSI surveillance in NHS hospitals in England covering 23 surgical procedures. Data collected were: (i) annual number of procedures, (ii) SSI rates from national reports, (iii) national reporting requirement (mandatory, voluntary, not offered), (iv) priority ranking from a survey of 84 English NHS hospitals, (v) excess length of stay and costs from the literature. The relationships between estimated SSI burden, national surveillance activity, and hospital-reported priorities were explored with descriptive and univariate analyses.FindingsAmong the 23 surgical categories analysed, top priority ranking by hospitals was associated only with current surveillance (r=0.76, p<0.01) and mandatory reporting (33% vs 8 and 4%, p=0.04). Percentage of hospitals undertaking surveillance, mandatory reporting, and the selection of priorities did not match SSI burden. Large bowel surgery (LBS, voluntary) and caesarean section (not offered) were the two highest contributors of total SSIs per annum, with 39,000 (38%) and 17,000 (16%) respectively, while the four orthopaedic categories (all mandatory) contributed 5,000 (5%). LBS also had the highest associated costs (£119m per annum).ConclusionCurrent surveillance and future priorities were not associated with SSI rate, volume, or cost to hospitals. The two highest contributors of SSIs and related costs have no (caesarean section) or limited (LBS) coverage by national surveillance.

  • Journal article
    Birgand G, Castro-Sánchez E, Hansen S, Gastmeier P, Lucet J-C, Ferlie E, Holmes A, Ahmad Ret al., 2018,

    Comparison of governance approaches for the control of antimicrobial resistance: Analysis of three European countries

    , Antimicrobial Resistance and Infection Control, Vol: 7, ISSN: 2047-2994

    Policy makers and governments are calling for coordination to address the crisis emerging from the ineffectiveness of current antibiotics and stagnated pipe-line of new ones - antimicrobial resistance (AMR). Wider contextual drivers and mechanisms are contributing to shifts in governance strategies in health care, but are national health system approaches aligned with strategies required to tackle antimicrobial resistance? This article provides an analysis of governance approaches within healthcare systems including: priority setting, performance monitoring and accountability for AMR prevention in three European countries: England, France and Germany. Advantages and unresolved issues from these different experiences are reported, concluding that mechanisms are needed to support partnerships between healthcare professionals and patients with democratized decision-making and accountability via collaboration. But along with this multi-stakeholder approach to governance, a balance between regulation and persuasion is needed.

  • Journal article
    Charani E, Ahmad R, Tarrant C, Birgand G, Leather A, Mendelson M, Moonesinghe SR, Sevdalis N, Singh S, Holmes Aet al., 2017,

    Opportunities for system level improvement in antibiotic use across the surgical pathway

    , International Journal of Infectious Diseases, Vol: 60, Pages: 29-34, ISSN: 1201-9712

    Optimizing antibiotic prescribing across the surgical pathway (before, during, and after surgery) is a key aspect of tackling important drivers of antimicrobial resistance and simultaneously decreasing the burden of infection at the global level. In the UK alone, 10 million patients undergo surgery every year, which is equivalent to 60% of the annual hospital admissions having a surgical intervention. The overwhelming majority of surgical procedures require effectively limited delivery of antibiotic prophylaxis to prevent infections. Evidence from around the world indicates that antibiotics for surgical prophylaxis are administered ineffectively, or are extended for an inappropriate duration of time postoperatively. Ineffective antibiotic prophylaxis can contribute to the development of surgical site infections (SSIs), which represent a significant global burden of disease. The World Health Organization estimates SSI rates of up to 50% in postoperative surgical patients (depending on the type of surgery), with a particular problem in low- and middle-income countries, where SSIs are the most frequently reported healthcare-associated infections. Across European hospitals, SSIs alone comprise 19.6% of all healthcare-acquired infections. Much of the scientific research in infection management in surgery is related to infection prevention and control in the operating room, surgical prophylaxis, and the management of SSIs, with many studies focusing on infection within the 30-day postoperative period. However it is important to note that SSIs represent only one of the many types of infection that can occur postoperatively. This article provides an overview of the surgical pathway and considers infection management and antibiotic prescribing at each step of the pathway. The aim was to identify the implications for research and opportunities for system improvement.

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