59 results found
Borek AJ, Campbell A, Dent E, et al., 2021, Implementing interventions to reduce antibiotic use: a qualitative study in high-prescribing practices, BMC FAMILY PRACTICE, Vol: 22
Honeyford K, Coughlan C, Nijman R, et al., 2021, Changes in emergency department activity and the first COVID-19 lockdown; a cross sectional study, Western Journal of Emergency Medicine : Integrating Emergency Care with Population Health, ISSN: 1936-900X
BackgroundEmergency Department (ED) attendances fell across the UK after the ‘lockdown’ introduced on 23rd March 2020 to limit the spread of coronavirus disease 2019 (COVID-19). We hypothesised that reductions would vary by patient age and disease type. We examined pre- and in-lockdown ED attendances for two COVID-19 unrelated diagnoses; one likely to be affected by lockdown measures (gastroenteritis) and one likely to be unaffected (appendicitis). MethodsRetrospective cross-sectional study conducted across two EDs in one London hospital Trust. We compared all adult and paediatric ED attendances, before (January 2020) and during lockdown (March/April 2020). Key patient demographics, method of arrival and discharge location were compared. We used SNOMED codes to define attendances for gastroenteritis and appendicitis. ResultsED attendances fell from 1129 per day before lockdown to 584 in-lockdown; 51.7% of pre-lockdown rates. In-lockdown attendances were lowest for under-18s (16.0% of pre-lockdown). The proportion of patients admitted to hospital increased from 17.3% to 24.0% and the proportion admitted to intensive care increased four-fold. Attendances for gastroenteritis fell from 511 to 103; 20.2% of pre-lockdown rates. Attendances for appendicitis also decreased, from 144 to 41; 28.5% of pre-lockdown rates.ConclusionED attendances fell substantially following lockdown implementation. The biggest reduction was for under-18s. We observed reductions in attendances for gastroenteritis and appendicitis. This may reflect lower rates of infectious disease transmission, though the fall in appendicitis-related attendances suggests that behavioural factors are also important. Larger studies are urgently needed to understand changing patterns of ED use and access to emergency care during the COVID-19 pandemic.
Boncea E, Expert P, Mitchell C, et al., 2021, Association between intrahospital transfer and hospital-acquired infection in the elderly: A retrospective case-control study in a UK hospital network, BMJ Quality & Safety, ISSN: 2044-5415
Venkatraman T, Honeyford K, Costelloe C, et al., 2021, Sociodemographic profiles, educational attainment and physical activity associated with The Daily Mile™ registration in primary schools in England – a national cross-sectional linkage study, Journal of Epidemiology and Community Health, Vol: 75, Pages: 137-144, ISSN: 0143-005X
ObjectiveTo examine primary school and local authority characteristics associated with registrationfor The Daily Mile (TDM), an active mile initiative aimed at increasing physical activity inchildren.DesignA cross-sectional linkage study using routinely collected data.SettingAll state funded primary schools in England from 2012-2018(n=15,815).Results3,502 of all 15,815(22.1%) state funded primary schools in England were registered to doTDM, ranging from 16% in the East Midlands region to 31% in Inner London.Primary schools registered for TDM had larger mean pupil numbers compared with schoolsthat had not registered (300 vs 269 respectively). There was a higher proportion of TDMregistered schools in urban areas compared with non-urban areas. There was local authorityvariation in the likelihood of school registration (ICC: 0.094).After adjusting for school and local authority characteristics, schools located in a majorurban conurbation (OR 1.46 (95%CI:1.24-1.71) urban vs. rural) and schools with a higherproportion of disadvantaged pupils had higher odds of being registered to the TDM (OR 1.16(95%CI:1.02-1.33)). Area based physical activity and schools’ educational attainment wasnot significantly associated with registration to TDM.ConclusionOne in five primary schools in England has registered for The Daily Mile since 2012. TDMappears to be a wide-reaching school based physical activity intervention that is reachingmore disadvantaged primary school populations in urban areas where obesity prevalence ishighest. TDM registered schools include those with both high and low educationalattainment and are in areas with high and low physical activity
Miller L, Costelloe CE, Robotham JV, et al., 2020, Overuse of antibiotics: Can viral vaccinations help stem the tide?, BRITISH JOURNAL OF CLINICAL PHARMACOLOGY, Vol: 87, Pages: 87-89, ISSN: 0306-5251
Pouwels KB, Vansteelandt S, Batra R, et al., 2020, Estimating the effect of healthcare-associated infections on excess length of hospital stay using inverse probability-weighted survival curves, Clinical Infectious Diseases, Vol: 71, Pages: e415-e420, ISSN: 1058-4838
BACKGROUND: Studies estimating excess length of stay (LOS) attributable to nosocomial infections have failed to address time-varying confounding, likely leading to overestimation of their impact. We present a methodology based on inverse probability-weighted survival curves to address this limitation. METHODS: A case study focusing on intensive care unit-acquired bacteremia using data from 2 general intensive care units (ICUs) from 2 London teaching hospitals were used to illustrate the methodology. The area under the curve of a conventional Kaplan-Meier curve applied to the observed data was compared with that of an inverse probability-weighted Kaplan-Meier curve applied after treating bacteremia as censoring events. Weights were based on the daily probability of acquiring bacteremia. The difference between the observed average LOS and the average LOS that would be observed if all bacteremia cases could be prevented was multiplied by the number of admitted patients to obtain the total excess LOS. RESULTS: The estimated total number of extra ICU days caused by 666 bacteremia cases was estimated at 2453 (95% confidence interval [CI], 1803-3103) days. The excess number of days was overestimated when ignoring time-varying confounding (2845 [95% CI, 2276-3415]) or when completely ignoring confounding (2838 [95% CI, 2101-3575]). CONCLUSIONS: ICU-acquired bacteremia was associated with a substantial excess LOS. Wider adoption of inverse probability-weighted survival curves or alternative techniques that address time-varying confounding could lead to better informed decision making around nosocomial infections and other time-dependent exposures.
Daunt A, Perez-Guzman PN, Liew F, et al., 2020, Validity of the UK early access to medicines scheme criteria for Remdesivir use in patients with COVID-19 disease, JOURNAL OF INFECTION, Vol: 81, Pages: 666-668, ISSN: 0163-4453
Boyd SE, Vasudevan A, Moore LSP, et al., 2020, Validating a prediction tool to determine the risk of nosocomial multidrug-resistant Gram-negative bacilli infection in critically ill patients: A retrospective case-control study, Journal of Global Antimicrobial Resistance, Vol: 22, Pages: 826-831, ISSN: 2213-7165
BACKGROUND: The Singapore GSDCS score was developed to enable clinicians predict the risk of nosocomial multidrug-resistant Gram-negative bacilli (RGNB) infection in critically ill patients. We aimed to validate this score in a UK setting. METHOD: A retrospective case-control study was conducted including patients who stayed for more than 24h in intensive care units (ICUs) across two tertiary National Health Service hospitals in London, UK (April 2011-April 2016). Cases with RGNB and controls with sensitive Gram-negative bacilli (SGNB) infection were identified. RESULTS: The derived GSDCS score was calculated from when there was a step change in antimicrobial therapy in response to clinical suspicion of infection as follows: prior Gram-negative organism, Surgery, Dialysis with end-stage renal disease, prior Carbapenem use and intensive care Stay of more than 5 days. A total of 110 patients with RGNB infection (cases) were matched 1:1 to 110 geotemporally chosen patients with SGNB infection (controls). The discriminatory ability of the prediction tool by receiver operating characteristic curve analysis in our validation cohort was 0.75 (95% confidence interval 0.65-0.81), which is comparable with the area under the curve of the derivation cohort (0.77). The GSDCS score differentiated between low- (0-1.3), medium- (1.4-2.3) and high-risk (2.4-4.3) patients for RGNB infection (P<0.001) in a UK setting. CONCLUSION: A simple bedside clinical prediction tool may be used to identify and differentiate patients at low, medium and high risk of RGNB infection prior to initiation of prompt empirical antimicrobial therapy in the intensive care setting.
Alturkistani A, Qavi A, Anyanwu PE, et al., 2020, Patient portal functionalities and patient outcomes among diabetes patients: a systematic, Publisher: JMIR Publications
Background:Patient portal use could help improve diabetes patients’ care and health outcomes due to the functionalities such as appointment booking, e-messaging, repeat prescription ordering that enable patient-centred care and improve the patient’s self-management of the disease.Objective:To summarise the evidence regarding the use of patient portal (portals that are connected to the electronic healthcare record) or patient portal functionality (e.g. appointment booking or e-messages) and their reported associations with health and healthcare quality outcomes among adult diabetes patients.Methods:We searched the databases including Medline, Embase and Scopus and reported the review methodology using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Three independent reviewers screened titles and abstracts, and two reviewers assessed full-texts of relevant studies and performed data extraction and quality assessments of the included studies. We used the Cochrane Collaboration Risk of Bias Tool and the National Heart, Lung and Blood Institute (NHLBI) Study Quality Assessment Tools to assess the risk of bias of the included studies. Data was summarised through narrative synthesis.Results:Twelve studies were included in this review. Five studies reported overall patient portal use and its association with diabetes health and healthcare quality outcomes. Six studies reported E-messaging or email use associated outcomes and two studies reported prescription refill associated outcomes. Reported associations included the association between patient portal use and blood pressure, LDL cholesterol or BMI. Few studies reported outcomes regarding the use of patient portals and healthcare utilisation measures such as office visits, emergency department visits and hospitalisations. Limited number of studies reported overall quality of care for diabetes patients who used patient portals.Conclusions:The included studies mostly r
Alturkistani A, Greenfield G, Greaves F, et al., 2020, Patient portal functionalities and uptake: a systematic review protocol, JMIR Research Protocols, Vol: 9, ISSN: 1929-0748
Background: Patient portals are digital health tools adopted by healthcare organisations. The portals are generally connected to the electronic health record of the healthcare organisation and offer patients functionalities such as access to the medical record, ability to order repeat prescriptions, make appointments or message the healthcare provider. Patient portals may be beneficial for patients and for the healthcare system. Patient portals can widely differ from one context to another due to the differences in the portal functionalities and capabilities and it is anticipated that outcomes associated with the functionalities to differ as well. Current systematic reviews report outcomes associated with patient portal uptake but do not explicitly specify the patient portal functionalities. Objective: The aim of this systematic review is to synthesise the evidence on health and healthcare quality outcomes associated with patient portal use among adult (18 years or older) patients. The review research questions are: What kind of health outcomes do tethered patient portals and patient portal functionalities contribute to in adult patients (18 years or older)? and What kind of healthcare quality outcomes including healthcare utilisation outcomes, do tethered patient portals and patient portal functionalities contribute to in adult patients (18 years or older)? Methods: The systematic review will be conducted by searching the Medline, Embase, and Scopus databases for relevant literature. The review inclusion criteria will be studies about adult patients (18 years or older), studies only about tethered patient portals and studies with or without a comparator. We will report patient portal-associated health and healthcare quality outcomes based on the patient portal functionalities. All quantitative primary study types will be included. Risk of bias of included studies will be assessed using the Cochrane Collaboration’s tool for assessing risk of bias in randomised
Anyanwu PE, Pouwels K, Walker A, et al., 2020, Investigating the mechanism of impact and differential effect of the Quality Premium scheme on antibiotic prescribing in England: a longitudinal study, BJGP Open, Vol: 4, Pages: 1-12, ISSN: 2398-3795
BACKGROUND: In 2017, approximately 73% of antibiotics in England were prescribed from primary care practices. It has been estimated that 9%-23% of antibiotic prescriptions between 2013 and 2015 were inappropriate. Reducing antibiotic prescribing in primary care was included as one of the national priorities in a financial incentive scheme in 2015-2016. AIM: To investigate whether the effects of the Quality Premium (QP), which provided performance-related financial incentives to clinical commissioning groups (CCGs), could be explained by practice characteristics that contribute to variations in antibiotic prescribing. DESIGN & SETTING: Longitudinal monthly prescribing data were analysed for 6251 primary care practices in England from April 2014 to March 2016. METHOD: Linear generalised estimating equations models were fitted, examining the effect of the 2015-2016 QP on the number of antibiotic items per specific therapeutic group age-sex related prescribing unit (STAR-PU) prescribed, adjusting for seasonality and months since implementation. Consistency of effects after further adjustment for variations in practice characteristics were also examined, including practice workforce, comorbidities prevalence, prescribing rates of non-antibiotic drugs, and deprivation. RESULTS: Antibiotics prescribed in primary care practices in England reduced by -0.172 items per STAR-PU (95% confidence interval [CI] = -0.180 to -0.171) after 2015-2016 QP implementation, with slight increases in the months following April 2015 (+0.014 items per STAR-PU; 95% CI = +0.013 to +0.014). Adjusting the model for practice characteristics, the immediate and month-on-month effects following implementation remained consistent, with slight attenuation in immediate reduction from -0.172 to -0.166 items per STAR-PU. In subgroup analysis, the QP effect was significantly greater among the top 20% prescribing practices (interaction p<0.001). Practices with low workforce and those with higher diabet
Vollmer M, Radhakrishnan S, Kont M, et al., 2020, Report 29: The impact of the COVID-19 epidemic on all-cause attendances to emergency departments in two large London hospitals: an observational study
The health care system in England has been highly affected by the surge in demand due to patients afflicted by COVID-19. Yet the impact of the pandemic on the care seeking behaviour of patients and thus on Emergency department (ED) services is unknown, especially for non-COVID-19 related emergencies. In this report, we aimed to assess how the reorganisation of hospital care and admission policies to respond to the COVID-19 epidemic affected ED attendances and emergency hospital admissions. We performed time-series analyses of present year vs historic (2015-2019) trends of ED attendances between March 12 and May 31 at two large central London hospitals part of Imperial College Healthcare NHS Trust (ICHNT) and compared these to regional and national trends. Historic attendances data to ICHNT and publicly available NHS situation reports were used to calibrate time series auto-regressive integrated moving average (ARIMA) forecasting models. We thus predicted the (conterfactual) expected number of ED attendances between March 12 (when the first public health measure leading to lock-down started in England) to May 31, 2020 (when the analysis was censored) at ICHNT, at all acute London Trusts and nationally. The forecasted trends were compared to observed data for the same periods of time. Lastly, we analysed the trends at ICHNT disaggregating by mode of arrival, distance from postcode of patient residence to hospital and primary diagnosis amongst those that were subsequently admitted to hospital and compared these data to an average for the same period of time in the years 2015 to 2019.During the study period (January 1 to May 31, 2020) there was an overall decrease in ED attendances of 35% at ICHNT, of 50% across all London NHS Trusts and 53% nationally. For ICHNT, the decrease in attendances was mainly amongst those aged younger than 65 and those arriving by their own means (e.g. personal or public transport). Increasing distance (km) from postcode of residence to hospi
Anyanwu P, Costelloe C, Majeed A, et al., 2020, 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
BackgroundAbout 73% of antibiotics in England are prescribed from primary care practices.AimTo investigate whether effects of the Quality Premium (QP), which provided performance-related financial incentives to Clinical Commissioning Groups, could be explained by practice characteristics that contribute to variations in antibiotic prescribing.Design and settingWe analysed longitudinal monthly prescribing data for 6,251 primary care practices in England from April 2014 to March 2016.MethodWe fitted linear generalised estimating equations models examining the effect of 2015/16 QP on number of antibiotic items per Specific Therapeutic group Age-sex Related Prescribing Unit (STAR-PU) prescribed, adjusting for seasonality and months since implementation; and examined consistency of effects after further adjustment for variations in practice characteristics, including practice workforce, co-morbidities prevalence, prescribing rates of non-antibiotic drugs, and deprivation.ResultsAntibiotics prescribed in primary care practices in England reduced by -0.172 items/STAR-PU (95% CI: -0.180 to -0.171) after 2015/16 QP implementation, with slight increases in the months following April 2015 (+0.014 items/STAR-PU; 95% CI: +0.013 to +0.014). Adjusting the model for practice characteristics, the immediate and month-on-month effects following implementation remained consistent, with slight attenuation in immediate reduction from -0.172 to -0.166 items/STAR-PU. In subgroup analysis, the QP effect was significantly greater among the top 20% prescribing practices (interaction p<0.001). Practices with low workforce and those with higher diabetes prevalence had greater reductions in prescribing following 2015/16 QP compared to other practices (interaction p<0.001).ConclusionHigh prescribing practices, those with low workforce and high diabetes prevalence had more reduction following the QP compared to other practices, highlighting the need for targeted support of these practices an
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., 2018, 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)
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