Publications
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Rabinowicz S, O'Hare M, Moore LSP, et al., 2019, Xpert MRSA screening in surgical patient flow; time for a rethink for hub-and-spoke laboratory models?, Journal of Medical Microbiology, Vol: 68, Pages: 290-291, ISSN: 1473-5644
The move towards pathology networks and hub-and-spoke models of medical laboratory service provision has significantly changed the flow of samples, and the impact of results on patients, over recent years. At the same time advances in technology, including rapid, simple to use molecular platforms, are changing the way microbiology results can be utilized. Like many other medical microbiology laboratories, we struggle with this balance for many different sample types and test requests. Work published by Neilson et al. in Journal of Medical Microbiology last year looked at this balance for methicillin-resistant Staphylococcus aureus (MRSA) genotypic diagnostics and suggested significant cost savings when a whole-healthcare economy perspective was adopted. However, as with all changes, implementing MRSA molecular diagnostics in different clinical settings must be considered carefully. We add to this discussion in our accompanying letter, detailing our experience (in a hub-and-spoke medical microbiology laboratory setting) of 'rapid' MRSA molecular diagnostics for day-case surgery where pre-operative assessment had been missed, exploring the impact and costs of these tests. We find no impact on patient care, but at considerable additional cost. We hope this will add a cautionary note to those considering implementing molecular microbiology diagnostics, and reopen the debate on where, in hub-and-spoke laboratory models, such devices should be situated.
Saleh M, Ebrahimsa M, Mughal N, et al., 2019, Helminth serology testing pathways could make significant savings in a non-endemic healthcare settings, European Congress of Clinical Microbiology & Infectious Diseases
Moore LSP, Hatcher JC, 2019, Infectious Diseases, Microbiology and Virology: A Q and A Approach for Specialist Medical Trainees, ISBN: 9781316609712
An essential resource for practitioners in infectious diseases and microbiology, studying for the new FRC Path Part 1 infection examination accredited by the Royal College of Pathologists, and trainees sitting the membership exams of the Royal College of Physicians. Including over 300 multiple choice questions in an exam-style Q&A format, this guide provides an invaluable revision platform for domestic and international trainees alike, with scope to present infection-based support for other medical specialties, where infection forms a core component, including intensive care. Authored by leading specialists in infectious diseases and microbiology, this invaluable training guide is the first of its kind to cover both undergraduate and postgraduate material in infectious diseases. Mapping directly from the FRCPath and RCP infection curricula, students are able to explore areas of curriculum to gain knowledge and optimise decision-making skills, under pressure.
Herrero P, Rawson TM, Philip A, et al., 2018, Closed-loop control for precision antimicrobial delivery: an In silico proof-of-concept, IEEE Transactions on Biomedical Engineering, Vol: 65, Pages: 2231-2236, ISSN: 0018-9294
IEEE Objective: Inappropriate dosing of patients with antibiotics is a driver of antimicrobial resistance, toxicity, and poor outcomes of therapy. In this paper, we investigate, in silico, the hypothesis that the use of a closed-loop control system could improve the attainment of pharmacokinetic-pharmacodynamic targets for antimicrobial therapy, where wide variations in target attainment have been reported. This includes patients in critical care, patients with renal disease and patients with obesity.
Abdolrasouli A, Petrou MA, Park H, et al., 2018, Surveillance for azole-resistant Aspergillus fumigatus in a centralized diagnostic mycology service, London, United Kingdom, 1998-2017, Frontiers in Microbiology, Vol: 9, ISSN: 1664-302X
Background/Objectives: Aspergillus fumigatus is the leading cause of invasive aspergillosis. Treatment is hindered by the emergence of resistance to triazole antimycotic agents. Here, we present the prevalence of triazole resistance among clinical isolates at a major centralized medical mycology laboratory in London, United Kingdom, in the period 1998–2017.Methods: A large number (n = 1469) of clinical A. fumigatus isolates from unselected clinical specimens were identified and their susceptibility against three triazoles, amphotericin B and three echinocandin agents was carried out. All isolates were identified phenotypically and antifungal susceptibility testing was carried out by using a standard broth microdilution method.Results: Retrospective surveillance (1998–2011) shows 5/1151 (0.43%) isolates were resistant to at least one of the clinically used triazole antifungal agents. Prospective surveillance (2015–2017) shows 7/356 (2.2%) isolates were resistant to at least one triazole antifungals demonstrating an increase in incidence of triazole-resistant A. fumigatus in our laboratory. Among five isolates collected from 2015 to 2017 and available for molecular testing, three harbored TR34/L98H alteration in the cyp51A gene that are associated with the acquisition of resistance in the non-patient environment.Conclusion: These data show that historically low prevalence of azole resistance may be increasing, warranting further surveillance of susceptible patients.
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.
Hernandez B, Herrero P, Rawson TM, et al., 2018, Enhancing antimicrobial surveillance: an automated, dynamic and interactive approach, 18th International Congress on Infectious Disease, Publisher: Elsevier, Pages: 122-122, ISSN: 1201-9712
McKean A, Aggarwal D, Torres-Grau J, et al., 2018, Is flucloxacillin monotherapy sufficient for the treatment of skin and soft tissue infections in plastic surgery?, Journal of Plastic, Reconstructive and Aesthetic Surgery, Vol: 71, Pages: 919-920, ISSN: 1748-6815
Welman T, McKean AR, Duggan E, et al., 2018, Tetanus 'Quick Stik' - is the NHS missing a trick?, Injury, Vol: 49, Pages: 1240-1241, ISSN: 0020-1383
Rawson T, Charani E, Moore L, et al., 2018, Exploring the use of C-Reactive Protein to Estimate the Pharmacodynamics of Vancomycin, Therapeutic Drug Monitoring, Vol: 40, Pages: 315-321, ISSN: 0163-4356
BackgroundC-reactive protein (CRP) pharmacodynamic (PD) models have the potential to provide adjunctive methods for predicting the individual exposure-response to antimicrobial therapy. We investigated CRP PD linked to a vancomycin PK model using routinely collected data from non-critical care adults in secondary care.MethodsPatients receiving intermittent intravenous vancomycin therapy in secondary care were identified. A two-compartment vancomycin PK model was linked to a previously described PD model describing CRP response. PK and PD parameters were estimated using a Non-Parametric Adaptive Grid technique. Exposure-response relationships were explored with vancomycin area-under-the-curve (AUC) and the index, AUC:EC50, fitted to CRP data using a sigmoidal Emax model. ResultsTwenty-nine individuals were included. Median age was 62 (21-97) years. Fifteen (52%) patients were microbiology confirmed. PK and PD models were adequately fitted (r2 0.83 and 0.82 respectively). There was a wide variation observed in individual Bayesian posterior EC50 estimates (6.95-48.55mg/L), with mean (SD) AUC:EC50 of 31.46 (29.22). AUC:EC50 was fitted to terminal CRP with AUC:EC50 >19 associated with lower CRP value at 96-120 hours of therapy (100mg/L vs. 44mg/L; p<0.01). ConclusionThe use of AUC:EC50 has the potential to provide in-vivo organism and host response data as an adjunct for in-vitro MIC data, which is currently used as the gold standard PD index for vancomycin therapy. This index can be estimated using routinely collected clinical data. Future work must investigate the role of AUC:EC50 in a prospective cohort and explore linkage with direct patient outcomes.
Macneal P, Rahman S, Moore L, et al., 2018, Rapid microbial diagnosis in burns patients: Time for a change?, BURNS, Vol: 44, Pages: 1020-1021, ISSN: 0305-4179
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Dagens A, Mughal N, Sisson A, et al., 2018, Experience of using beta-D-glucan assays in the intensive care unit, CRITICAL CARE, Vol: 22, Pages: 125-125, ISSN: 1466-609X
Rawson T, o'hare D, Herrero P, et al., 2018, Delivering precision antimicrobial therapy through closed-loop control systems, Journal of Antimicrobial Chemotherapy, Vol: 73, Pages: 835-843, ISSN: 0305-7453
Sub-optimal exposure to antimicrobial therapy is associated with poor patient outcomes and the development of antimicrobial resistance. Mechanisms for optimizing the concentration of a drug within the individual patient are under development. However, several barriers remain in realizing true individualization of therapy. These include problems with plasma drug sampling, availability of appropriate assays, and current mechanisms for dose adjustment. Biosensor technology offers a means of providing real-time monitoring of antimicrobials in a minimally invasive fashion. We report the potential for using microneedle biosensor technology as part of closed-loop control systems for the optimization of antimicrobial therapy in individual patients.
Bull L, Tittle V, Hughes S, et al., 2018, Exploring the epidemiology and management of shigellosis in a large acute hospital trust, 4th joint BHIVA/BASSH Conference, Publisher: WILEY, Pages: S9-S9, ISSN: 1464-2662
Rawson T, Moore L, Castro Sanchez E, et al., 2018, Development of a patient-centred intervention to improve knowledge and understanding of antibiotic therapy in secondary care, Antimicrobial Resistance and Infection Control, Vol: 7, ISSN: 2047-2994
Introduction: We developed a personalised antimicrobial information module co-designed with patients. This study aimed to evaluate the potential impact of this patient-centred intervention on short-term knowledge and understanding of antimicrobial therapy in secondary care. Methods:Thirty previous patients who had received antibiotics in hospital within 12 months were recruited to co-design an intervention to promote patient engagement with infection management. Two workshops, containing five focus-groups were held. These were audio-recorded. Data were analysed using a thematic framework developed deductively based on previous work. Line-by-line coding was performed with new themes added to the framework by two researchers. This was used to inform the development of a patient information module, embedded within an electronic decision support tool (CDSS). The intervention was piloted over a four-week period at Imperial College Healthcare NHS Trust on 30 in-patients. Pre- and post-intervention questionnaires were developed and implemented to assess short term changes in patient knowledge and understanding and provide feedback on the intervention. Data were analysed using SPSS and NVIVO software. Results: Within the workshops, there was consistency in identified themes. The participants agreed upon and co-designed a personalised PDF document that could be integrated into an electronic CDSS to be used by healthcare professionals at the point-of-care. Their aim for the tool was to provide individualised practical information, signpost to reputable information sources, and enhance communication between patients and healthcare professionals.Eighteen out of thirty in-patients consented to participant in the pilot evaluation with 15/18(83%) completing the study. Median (range) age was 66(22-85) years. The majority were male (10/15;66%). Pre-intervention, patients reported desiring further information regarding their infections and antibiotic therapy, including side effects
Rudd E, Francis N, Moore L, et al., 2018, An erythematous papular rash on the left flank of a 31-year-old woman: A quiz, Acta Dermato-Venereologica, Vol: 98, Pages: 477-478, ISSN: 0001-5555
Hernandez Perez B, Herrero Viñas P, Miles Rawson T, et al., 2017, Supervised Learning for Infection Risk Inference Using Pathology Data, BMC Medical Informatics and Decision Making, Vol: 17, ISSN: 1472-6947
Background: Antimicrobial Resistance is threatening our ability to treat common infectious diseases and overuse of antimicrobials to treat human infections in hospitals is accelerating this process. Clinical Decision Support Systems (CDSSs) have been proven to enhance quality of care by promoting change in prescription practices through antimicrobial selection advice. However, bypassing an initial assessment to determine the existence of an underlying disease that justifies the need of antimicrobial therapy might lead to indiscriminate and often unnecessary prescriptions.Methods: From pathology laboratory tests, six biochemical markers were selected and combined with microbiology outcomes from susceptibility tests to create a unique dataset with over one and a half million daily profiles to perform infection risk inference. Outliers were discarded using the inter-quartile range rule and several sampling techniques were studied to tackle the class imbalance problem. The first phase selects the most effective and robust model during training using four-fold stratified cross-validation. The second phase evaluates the final model after isotonic calibration in scenarios with missing inputs and imbalanced class distributions. Results: More than 50\% of infected profiles have daily requested laboratory tests for the six biochemical markers with very promising infection inference results: area under the receiver operating characteristic curve (0.80-0.83), sensitivity (0.64-0.75) and specificity (0.92-0.97). Standardization consistently outperforms normalization and sensitivity is enhanced by using the SMOTE sampling technique. Furthermore, models operated without noticeable loss in performance if at least four biomarkers were available.Conclusion: The selected biomarkers comprise enough information to perform infection risk inference with a high degree of confidence even in the presence of incomplete and imbalanced data. Since they are commonly available in hospitals, Clini
Eades C, Hughes S, Heard K, et al., 2017, Antimicrobial therapies for Gram-positive infections, Clinical Pharmacist, Vol: 9, ISSN: 1758-9061
Gram-positive bacteria are among the most common human pathogens associated with clinical infections, which range from mild skin infections to sepsis. In an era defined by antimicrobial resistance (AMR) and an increasing drive toward delivering patient care via ambulatory pathways, the paradigm for the management of infections is changing. Methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE), the best known cases of Gram-positive resistance, are increasingly prevalent and may be associated with significantly worse clinical outcomes versus wild-type strains using current therapeutics. This article reviews the spectrum of antimicrobial agents currently available for the treatment of Gram-positive infections with a special focus on AMR, and outpatient antimicrobial therapy (OPAT). Also reviewed are agents currently in development, and renaissance roles for older antimicrobials in cases complicated by AMR.
Boyd S, moore LSP, Rawson TM, et al., 2017, Combination therapy for carbapenemase-producing Entero-bacteriaceae: INCREMENT-al effect on resistance remains unclear, The Lancet Infectious Diseases, Vol: 17, Pages: 899-900, ISSN: 1473-3099
Rawson T, Castro Sanchez E, Charani E, et al., 2017, Involving citizens in priority setting for public health research: implementation in infection research, Health Expectations, Vol: 21, Pages: 222-229, ISSN: 1369-7625
BackgroundPublic sources fund the majority of UK infection research, but citizens currently have no formal role in resource allocation. To explore the feasibility and willingness of citizens to engage in strategic decision making, we developed and tested a practical tool to capture public priorities for research.MethodA scenario including six infection themes for funding was developed to assess citizen priorities for research funding. This was tested over two days at a university public festival. Votes were cast anonymously along with rationale for selection. The scenario was then implemented during a three-hour focus group exploring views on engagement in strategic decisions and in-depth evaluation of the tool.Results188/491(38%) prioritized funding research into drug-resistant infections followed by emerging infections(18%). Results were similar between both days. Focus groups contained a total of 20 citizens with an equal gender split, range of ethnicities and ages ranging from 18 to >70 years. The tool was perceived as clear with participants able to make informed comparisons. Rationale for funding choices provided by voters and focus group participants are grouped into three major themes: (i) Information processing; (ii) Knowledge of the problem; (iii) Responsibility; and a unique theme within the focus groups (iv) The potential role of citizens in decision making. Divergent perceptions of relevance and confidence of “non-experts” as decision makers were expressed.ConclusionVoting scenarios can be used to collect, en-masse, citizens' choices and rationale for research priorities. Ensuring adequate levels of citizen information and confidence is important to allow deployment in other formats.
Birgand GJC, Troughton R, Moore L, et al., 2017, Blogging in infectious diseases and clinical microbiology: Assessment of the 'blogosphere' content, Infection Control and Hospital Epidemiology, Vol: 38, Pages: 832-839, ISSN: 1559-6834
Objective.To analyzeinfluential infectious diseases, antimicrobial stewardship, infection control, or medical microbiology blogs and bloggers.Setting. World Wide WebDesign. We conducted a systematic search for blogs in accordance with the PRISMA guidelines in September 2015.Methods.A snowball sampling approach was applied to identify blogs using various search engines. Blogs were eligible if they: 1) focused on infectious diseases (ID), antimicrobial stewardship (AMS), infection control (IC), or medical microbiology (MM); 2) were intended for health professionals, 3) were written in English and updated regularly. We mapped blogs/bloggers characteristics and used an innovative tool to assess their architecture and content. Motivations and perceptions of bloggers and readers were assessed. Results.A total of 88 blogs were identified. 28 (32%) focused on ID, 46 (52%) on MM and 14 (16%) in IC or AMS. Bloggers were mainly male, MD and/or PhD, 32 (36%) posted at least weekly, and 51 (58%) for a research purpose. The aims were considered clear for 23 (26%) blogs, the field covered was broad for 25 (28%), presentation was good for 22 (25%), 51 were easy to read (58%) and 46 included expert interpretation (52%). Among the top 10 blogs (2 equally-ranked), 3 focused on ID, 6 on MM and 2 on IC. Bloggers questioned were motivated by sharing independent expertise/opinion. Readers appreciated the concise messages given on scientific and practical updates.Conclusions.This study describes high level blogs in ID/IC/MM suggesting how bloggers should build/orientate blogs for readers, and highlighting current gaps in topics such as AMS.
Rawson T, moore L, Hernandez B, et al., 2017, A systematic review of clinical decision support systems for antimicrobial management: Are we failing to investigate these interventions appropriately?, Clinical Microbiology and Infection, Vol: 23, Pages: 524-532, ISSN: 1469-0691
ObjectivesClinical decision support systems (CDSS) for antimicrobial management can support clinicians to optimise antimicrobial therapy. We reviewed all original literature (qualitative and quantitative) to understand the current scope of CDSS for antimicrobial management and analyse existing methods used to evaluate and report such systems. MethodPRISMA guidelines were followed. Medline, EMBASE, HMIC Health and Management, and Global Health databases were searched from 1st January 1980 to 31st October 2015. All primary research studies describing CDSS for antimicrobial management in adults in primary or secondary care were included. For qualitative studies, thematic synthesis was performed. Quality was assessed using Integrated quality Criteria for the Review Of Multiple Study designs (ICROMS) criteria. CDSS reporting was assessed against a reporting framework for behaviour change intervention implementation.ResultsFifty-eight original articles were included describing 38 independent CDSS. The majority of systems target antimicrobial prescribing (29/38;76%), are platforms integrated with electronic medical records (28/38;74%), and have rules based infrastructure providing decision support (29/38;76%). On evaluation against the intervention reporting framework, CDSS studies fail to report consideration of the non-expert, end-user workflow. They have narrow focus, such as antimicrobial selection, and use proxy outcome measures. Engagement with CDSS by clinicians was poor.ConclusionGreater consideration of the factors that drive non-expert decision making must be considered when designing CDSS interventions. Future work must aim to expand CDSS beyond simply selecting appropriate antimicrobials with clear and systematic reporting frameworks for CDSS interventions developed to address current gaps identified in the reporting of evidence.
Charani E, Gharbi M, Moore LSP, et al., 2017, The effect of adding a mobile health intervention to a multimodal antimicrobial stewardship programme across three teaching hospitals – an interrupted time series study, Journal of Antimicrobial Chemotherapy, Vol: 72, Pages: 1825-1831, ISSN: 1460-2091
Objectives To evaluate the impact of adding a mobile health (mHealth) decision support system for antibiotic prescribing to an established antimicrobial stewardship programme (ASP). Methods In August 2011, the antimicrobial prescribing policy was converted into a mobile application (app). A segmented regression analysis of interrupted time series was used to assess the impact of the app on prescribing indicators using data (2008-2014) from a biannual point prevalence study (PPS) in medicine and surgery wards. There were six data points pre and six data points post-implementation. Results There was an increase in compliance with policy (e.g. compliance with empirical therapy or expert advice) in medicine (6.48%, CI -1.25—14.20) and surgery (6.63%, CI 0.15—13.10) in the implementation period, with a significant sudden change in level in surgery (p<0.05). There was an increase, though not significant, in medicine (15.20%, CI 17.81—48.22) and surgery (35.97%, -3.72—75.66) in the percentage of prescriptions that had a stop/review date documented. The documentation of indication decreased in both medicine (-16.25%, CI -42.52—10.01) and surgery (-14.62%, CI -42.88—13.63).Conclusion Introducing the ‘app’ to an existing ASP had a significant impact on the compliance to policy in surgery, and a positive but not significant effect on documentation of stop/review date in both specialties. The negative effect on the third indicator may have been due to existing ASP efforts. The broader value of providing an antimicrobial policy on a digital platform e.g. the reach and access to the policy, should be measured using indicators more sensitive to mHealth interventions.
Hernandez B, Herrero P, Rawson TM, et al., 2017, Data-drivenWeb-based Intelligent Decision Support System for Infection Management at Point-Of-Care: Case-Based Reasoning Benefits and Limitations, 10th International Joint Conference on Biomedical Engineering Systems and Technologies, Publisher: SCITEPRESS, Pages: 119-127
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
Rawson T, Moore L, Tivey A, et al., 2017, Behaviour change interventions to influence antimicrobial prescribing: a cross-sectional analysis of reports from UK state-of-the-art scientific conferences, Antimicrobial Resistance and Infection Control, Vol: 6, ISSN: 2047-2994
BackgroundTo improve the quality of antimicrobial stewardship (AMS) interventions the application of behavioural sciences supported by multidisciplinary collaboration has been recommended. We analysed major UK scientific research conferences to investigate AMS behaviour change intervention reporting. MethodsLeading UK 2015 scientific conference abstracts for 30 clinical specialties were identified and interrogated. All AMS and/or antimicrobial resistance(AMR) abstracts were identified using validated search criteria. Abstracts were independently reviewed by four researchers with reported behavioural interventions classified using a behaviour change taxonomy. ResultsConferences ran for 110 days with >57,000 delegates. 311/12,313(2.5%) AMS-AMR abstracts (oral and poster) were identified. 118/311(40%) were presented at the UK’s infectious diseases/microbiology conference. 56/311(18%) AMS-AMR abstracts described behaviour change interventions. These were identified across 12/30(40%) conferences. The commonest abstract reporting behaviour change interventions were quality improvement projects [44/56 (79%)]. In total 71 unique behaviour change functions were identified. Policy categories; “guidelines” (16/71) and “service provision” (11/71) were the most frequently reported. Intervention functions; “education” (6/71), “persuasion” (7/71), and “enablement” (9/71) were also common. Only infection and primary care conferences reported studies that contained multiple behaviour change interventions. The remaining 10 specialties tended to report a narrow range of interventions focusing on “guidelines” and “enablement”. ConclusionDespite the benefits of behaviour change interventions on antimicrobial prescribing, very few AMS-AMR studies reported implementing them in 2015. AMS interventions must focus on promoting behaviour change towards antimicrobial prescribing. Greater focus must b
Rawson T, Charani E, Moore L, et al., 2016, Vancomycin therapy in secondary care; investigating factors that impact therapeutic target attainment, Journal of Infection, Vol: 74, Pages: 320-324, ISSN: 1532-2742
Rawson T, Charani E, Moore L, et al., 2016, Mapping the decision pathways of acute infection management in secondary care among UK medical physicians: a qualitative study, BMC Medicine, Vol: 14, ISSN: 1741-7015
BackgroundThe inappropriate use of antimicrobials drives antimicrobial resistance. We conducted a study to map physician decision making processes for acute infection management in secondary care to identify potential targets for quality improvement interventions.MethodsNewly qualified to Consultant level physicians participated in semi-structured interviews. Interviews were audio recorded and transcribed verbatim for analysis using NVIVO11.0 software. Grounded theory methodology was applied. Analytical categories were created using constant comparison approach to the data and participants were recruited to the study until thematic saturation was reached. ResultsTwenty physicians were interviewed. The decision pathway for the management of acute infections follows a Bayesian-like step-wise approach, with information processed and systematically added to prior assumptions to guide management. The main emerging themes identified as determinants of the decision making of individual physicians were; (i) perceptions of providing “optimal” care for the patient with infection by providing rapid and often intravenous therapy; (ii) perceptions that stopping/de-escalating therapy was a senior doctor decision with junior trainees not expected to contribute; (iii) expectation of interactions with local guidelines and microbiology service advice. Feedback on review of junior doctor prescribing decisions was often lacking, causing frustration and confusion on appropriate practice within this cohort. ConclusionInterventions to improve infection management must incorporate mechanisms to promote distribution of responsibility for decisions made. The disparity between expectations of prescribers to start but not review/stop therapy requires addressing urgently with mechanisms to improve communication and feedback to junior prescribers to facilitate their continued development as prudent antimicrobial prescribers.
Rawson T, Moore L, Hernandez B, et al., 2016, Patient engagement with infection management in secondary care: a qualitative investigation of current experiences, BMJ Open, Vol: 6, ISSN: 2044-6055
Objective To understand patient engagement with decision-making for infection management in secondary care and the consequences associated with current practices.Design A qualitative investigation using in-depth focus groups.Participants Fourteen members of the public who had received antimicrobials from secondary care in the preceding 12 months in the UK were identified for recruitment. Ten agreed to participate. All participants had experience of infection management in secondary care pathways across a variety of South-East England healthcare institutes. Study findings were subsequently tested through follow-up focus groups with 20 newly recruited citizens.Results Participants reported feelings of disempowerment during episodes of infection in secondary care. Information is communicated in a unilateral manner with individuals ‘told’ that they have an infection and will receive an antimicrobial (often unnamed), leading to loss of ownership, frustration, anxiety and ultimately distancing them from engaging with decision-making. This poor communication drives individuals to seek information from alternative sources, including online, which is associated with concerns over reliability and individualisation. Failures in communication and information provision by clinicians in secondary care influence individuals’ future ideas about infections and their management. This alters their future actions towards antimicrobials and can drive prescription non-adherence and loss to follow-up.Conclusions Current infection management and antimicrobial prescribing practices in secondary care fail to engage patients with the decision-making process. Secondary care physicians must not view infection management episodes as discrete events, but as cumulative experiences which have the potential to shape future patient behaviour and understanding of antimicrobial use.
Rawson T, Moore L, Gill D, et al., 2016, Promoting medical student engagement with antimicrobial stewardship through involvement in undergraduate research, Journal of Infection, Vol: 74, Pages: 200-202, ISSN: 1532-2742
The National Health Service recognises the importance of research, teaching, and training tothe future success of the organisation and medical students are expected to qualify with thenecessary clinical, professional, and academic skills to support this. There is a wide variationin the level of cross-specialty engagement with Antimicrobial Stewardship (AMS) &Antimicrobial resistance (AMR) research at UK and international state-of-the-artconferences, with a heterogeneous level of importance also attributed amongst undergraduateand postgraduate training pathways across clinical medicine. It therefore seems apparent thatthe AMS-AMR agenda needs to be promoted from within specialties, rather than being‘pushed’ on them as an external agenda, to promote broad ownership and capacity within allclinical specialties that use antimicrobials. This must start early during undergraduate medicaltraining. We investigated whether the use of an online platform designed to facilitate medicalstudent research projects could be utilised to promote undergraduate engagement with AMSAMRat Imperial College School of Medicine between July 2015 and 2016. During thisperiod 12 applicants were appointed to 11 of the 13 advertised projects. So far, studentsundertaking these projects have achieved: 1 peer-reviewed publication, 3 national oralpresentations, 1 national prize, 1 international poster presentation, 3 national posterpresentations, and 2 further manuscripts are currently under peer-review. Furthermore,despite the students’ broad career interests there has been a high retention rate with studentsrequesting involvement in further AMS-AMR related activities. Further longitudinalassessment of this tool for promoting undergraduate engagement with AMS-AMR research isnow being explored.
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