Publications
24 results found
Hayhoe B, Tonkin-Crine S, McLeod M, et al., 2022, Implementing antibiotic stewardship in high prescribing English general practices: a mixed-methods study, British Journal of General Practice, Vol: 73, Pages: e164-e175, ISSN: 0960-1643
Background: Trials have identified antimicrobial stewardship (AMS) strategies that effectively reduce antibiotic use in primary care. However, many are not commonly used in England. We co-developed an implementation intervention to improve use of three AMS strategies; enhanced communication strategies, delayed prescriptions, and point-of-care C-Reactive Protein testing (POC-CRPT). Aim: To investigate the use of the intervention in high-prescribing practices and its effect on antibiotic prescribing. Design and setting: Nine high-prescribing practices had access to the intervention for 12 months from November 2019. This was primarily delivered remotely via a website with practices required to identify an ‘Antibiotic Champion’. Methods: We compared routinely collected prescribing data between intervention and 45 matched control practices using a difference-in-differences analysis. Intervention use was assessed through monitoring. Surveys and interviews were conducted with professionals to capture experiences of using the intervention. Results: There was no evidence that the intervention affected prescribing. Engagement with intervention materials differed substantially between practices and depended on individual Champions’ preconceptions of strategies and opportunity to conduct implementation tasks. Champions in five practices initiated changes to encourage use of at least one AMS strategy, mostly POC-CRPT; one practice chose all three. POC-CRPT was used more when allocated to one person. Conclusions: Clinicians need detailed information on exactly how to adopt AMS strategies. Strategies may be used more when allocated to one or two individuals. Remote, one-sided provision of AMS strategies is unlikely to change prescribing; initial clinician engagement and understanding needs to be monitored to avoid misunderstanding and sub-optimal use.
Chu A, Kumar A, Depoorter G, et al., 2022, Learning from electronic prescribing errors: a mixed methods study of junior doctors' perceptions of training and individualised feedback data, BMJ OPEN, Vol: 12, ISSN: 2044-6055
Nampoothiri V, Bonaconsa C, Bonaconsa S, et al., 2022, What does antimicrobial stewardship look like where you are? Global narratives from participants in a massive open online course, JAC-Antimicrobial Resistance, Vol: 4, ISSN: 2632-1823
Background:Whilst antimicrobial stewardship (AMS) is being implemented globally, contextual differences exist. We describe how the use of a massive open online course (MOOC) platform provided an opportunity to gather diverse narratives on AMS from around the world.Methods:A free 3 week MOOC titled ‘Tackling antimicrobial resistance: a social science approach’ was launched in November 2019. Learners were asked specific questions about their experiences of AMS via 38 optional free-text prompts dispersed throughout the modules. Content analysis was used to identify key emerging themes from the learners’ responses in the first three runs of the MOOC.Results:Between November 2019 and July 2020, 1464 learners enrolled from 114 countries. Overall, 199 individual learners provided a total of 1097 responses to the prompts. The diverse perspectives describe unique challenges present in different contexts including ill-defined roles for pharmacists and nurses in AMS; inadequate governance and policy inconsistencies in surveillance for antibiotic consumption and antimicrobial resistance (AMR) in some countries; lack of ownership of antibiotic decision-making and buy-in from different clinical specialties; and human resource and technological constraints. Patients’ knowledge, experiences and perspectives were recognized as a valuable source of information that should be incorporated in AMS initiatives to overcome cultural barriers to the judicious use of antibiotics.Conclusions:Analysis of learner comments and reflections identified a range of enablers and barriers to AMS implementation across different healthcare economies. Common challenges to AMS implementation included the role of non-physician healthcare workers, resource limitations, gaps in knowledge of AMR, and patient engagement and involvement in AMS.
Borek AJ, Maitland K, McLeod M, et al., 2021, Impact of the covid-19 pandemic on community antibiotic prescribing and stewardship: a qualitative interview study with general practitioners in England, Antibiotics, Vol: 10, ISSN: 2079-6382
The COVID-19 pandemic has had a profound impact on the delivery of primary care services. We aimed to identify general practitioners’ (GPs’) perceptions and experiences of how the COVID-19 pandemic influenced antibiotic prescribing and antimicrobial stewardship (AMS) in general practice in England. Twenty-four semi-structured interviews were conducted with 18 GPs at two time-points: autumn 2020 (14 interviews) and spring 2021 (10 interviews). Interviews were audio-recorded, transcribed and analysed thematically, taking a longitudinal approach. Participants reported a lower threshold for antibiotic prescribing (and fewer consultations) for respiratory infections and COVID-19 symptoms early in the pandemic, then returning to more usual (pre-pandemic) prescribing. They perceived the pandemic as having had less impact on antibiotic prescribing for urinary and skin infections. Participants perceived the changing ways of working and consulting (e.g., proportions of remote and in-person consultations) in addition to changing patient presentations and GP workloads as influencing the fluctuations in antibiotic prescribing. This was compounded by decreased engagement with, and priority of, AMS due to COVID-19-related urgent priorities. Re-engagement with AMS is needed, e.g., through reviving antibiotic prescribing feedback and targets/incentives. The pandemic disrupted, and required adaptations in, the usual ways of working and AMS. It is now important to identify opportunities, e.g., for re-organising ways of managing infections and AMS in the future.
Hayhoe B, 2021, Public preferences for delayed or immediate antibiotic prescriptions in UK primary care: a choice experiment, PLoS Medicine, Vol: 18, Pages: 1-20, ISSN: 1549-1277
Delayed (or ‘back-up’) antibiotic prescription, where the patient is given a prescription but advised todelay initiating antibiotics, has been shown to be effective in reducing antibiotic use in primary care.However, this strategy is not widely used in the UK. This study aimed to identify factors influencingpreferences among the UK public for delayed prescription, and understand their relative importance,to help increase appropriate use of this prescribing option.Methods and FindingsWe conducted an online choice experiment in two UK general population samples: adults, and parentsof children under 18 years. Respondents were presented with twelve scenarios in which they, or theirchild, might need antibiotics for a respiratory tract infection, and asked to choose either an immediateor a delayed prescription. Scenarios were described by seven attributes. Data were collected betweenNovember 2018 and February 2019. Respondent preferences were modelled using mixed-effectslogistic regression.The survey was completed by 802 adults and 801 parents (75% of those who opened the survey). Thesamples reflected the UK population in age, sex, ethnicity and country of residence. The mostimportant determinant of respondent choice was symptom severity, especially for cough-relatedsymptoms. In the adult sample the probability of choosing delayed prescription was 0.53 (95% CI 0.50-0.56, p<.001) for a chesty cough and runny nose, compared to 0.30 (0.28-0.33, p<.001) for a chestycough with fever, 0.47 (0.44-0.50, p<.001) for sore throat with swollen glands and 0.37 (0.34-0.39,p<.001) for sore throat, swollen glands and fever. Respondents were less likely to choose delayedprescription with increasing duration of illness (odds ratio 0.94 (0.92-0.96, p<0.001)). Probabilities ofchoosing delayed prescription were similar for parents considering treatment for a child (44% ofchoices vs. 42% for adults, p=0.04). However, parents differed from the adult sample in showing
Charani E, McKee M, Ahmad R, et al., 2021, Optimising antimicrobial use in humans-review of current evidence and an interdisciplinary consensus on key priorities for research, The Lancet Regional Health - Europe, Vol: 7, Pages: 1-10, ISSN: 2666-7762
Addressing the silent pandemic of antimicrobial resistance (AMR) is a focus of the 2021 G7 meeting. A major driver of AMR and poor clinical outcomes is suboptimal antimicrobial use. Current research in AMR is inequitably focused on new drug development. To achieve antimicrobial security we need to balance AMR research efforts between development of new agents and strategies to preserve the efficacy and maximise effectiveness of existing agents.Combining a review of current evidence and multistage engagement with diverse international stakeholders (including those in healthcare, public health, research, patient advocacy and policy) we identified research priorities for optimising antimicrobial use in humans across four broad themes: policy and strategic planning; medicines management and prescribing systems; technology to optimise prescribing; and context, culture and behaviours. Sustainable progress depends on: developing economic and contextually appropriate interventions; facilitating better use of data and prescribing systems across healthcare settings; supporting appropriate and scalable technological innovation. Implementing this strategy for AMR research on the optimisation of antimicrobial use in humans could contribute to equitable global health security.
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, ISSN: 1471-2296
BackgroundTrials have shown that delayed antibiotic prescriptions (DPs) and point-of-care C-Reactive Protein testing (POC-CRPT) are effective in reducing antibiotic use in general practice, but these were not typically implemented in high-prescribing practices. We aimed to explore views of professionals from high-prescribing practices about uptake and implementation of DPs and POC-CRPT to reduce antibiotic use.MethodsThis was a qualitative focus group study in English general practices. The highest antibiotic prescribing practices in the West Midlands were invited to participate. Clinical and non-clinical professionals attended focus groups co-facilitated by two researchers. Focus groups were audio-recorded, transcribed verbatim and analysed thematically.ResultsNine practices (50 professionals) participated. Four main themes were identified. Compatibility of strategies with clinical roles and experience – participants viewed the strategies as having limited value as ‘clinical tools’, perceiving them as useful only in ‘rare’ instances of clinical uncertainty and/or for those less experienced. Strategies as ‘social tools’ – participants perceived the strategies as helpful for negotiating treatment decisions and educating patients, particularly those expecting antibiotics. Ambiguities – participants perceived ambiguities around when they should be used, and about their impact on antibiotic use. Influence of context – various other situational and practical issues were raised with implementing the strategies.ConclusionsHigh-prescribing practices do not view DPs and POC-CRPT as sufficiently useful ‘clinical tools’ in a way which corresponds to the current policy approach advocating their use to reduce clinical uncertainty and improve antimicrobial stewardship. Instead, policy attention should focus on how these strategies may instead be used as ‘social tools’ to reduce unnecessary antibio
Zhu NJ, McLeod M, McNulty CAM, et al., 2021, Trends in Antibiotic Prescribing in Out-of-Hours Primary Care in England from January 2016 to June 2020 to Understand Behaviours during the First Wave of COVID-19, ANTIBIOTICS-BASEL, Vol: 10, ISSN: 2079-6382
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- Citations: 13
Morrell L, Buchanan J, Roope LSJ, et al., 2020, Delayed antibiotic prescription by general practitioners in the UK: a stated-choice study, ANTIBIOTICS-BASEL, Vol: 9, Pages: 1-19, ISSN: 2079-6382
Delayed antibiotic prescription in primary care has been shown to reduce antibiotic consumption, without increasing risk of complications, yet is not widely used in the UK. We sought to quantify the relative importance of factors affecting the decision to give a delayed prescription, using a stated-choice survey among UK general practitioners. Respondents were asked whether they would provide a delayed or immediate prescription in fifteen hypothetical consultations, described by eight attributes. They were also asked if they would prefer not to prescribe antibiotics. The most important determinants of choice between immediate and delayed prescription were symptoms, duration of illness, and the presence of multiple comorbidities. Respondents were more likely to choose a delayed prescription if the patient preferred not to have antibiotics, but consultation length had little effect. When given the option, respondents chose not to prescribe antibiotics in 51% of cases, with delayed prescription chosen in 21%. Clinical features remained important. Patient preference did not affect the decision to give no antibiotics. We suggest that broader dissemination of the clinical evidence supporting use of delayed prescription for specific presentations may help increase appropriate use. Establishing patient preferences regarding antibiotics may help to overcome concerns about patient acceptance. Increasing consultation length appears unlikely to affect the use of delayed prescription.
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
Mohsin-Shaikh S, Furniss D, Blandford A, et al., 2019, The impact of electronic prescribing systems on healthcare professionals' working practices in the hospital setting: a systematic review and narrative synthesis, BMC Health Services Research, Vol: 19, Pages: 1-8, ISSN: 1472-6963
BackgroundThe aim of this systematic review was to synthesise peer-reviewed literature assessing the impact of electronic prescribing (eP) systems on the working practices of healthcare professionals (HCPs) in the inpatient setting and identify implications for practice and research.MethodsWe searched PubMed, Medline, Embase, Cochrane and the Cumulative Index to Nursing Allied Health Literature databases for studies published from inception to November 2018. We included controlled, uncontrolled, observational and descriptive studies that explored the effect of eP on HCPs’ working practices in an inpatient setting. Data on setting, eP system and impact on working practices were extracted. Methodological quality was assessed using the Mixed Methods Appraisal Tool. Emergent themes were identified and subjected to narrative synthesis. The protocol was registered with PROSPERO (registration CRD42017075804).ResultsSearches identified 1301 titles and abstracts after duplicate removal. 171 papers underwent full-text review. A total of 25 studies met the inclusion criteria, from nine different countries. Nineteen were of commercial eP systems. There were a range of study designs; most (n = 14) adopted quantitative methods such as cross-sectional surveys, ten adopted qualitative approaches and a further one used mixed methods. Fourteen of the 25 studies were deemed to be of high quality. Four key themes were identified: communication, time taken to complete tasks, clinical workflow, and workarounds. Within each theme, study findings differed as to whether the effects of eP on HCPs’ working practices were positive or negative.ConclusionThere is a lack of consensus within the literature on the impact of eP on HCPs’ working practices. Future research should explore the strategies resulting in a positive impact on HCPs’ working practices and learn from those that have not been successful.
McLeod M, Ahmad R, Shebl NA, et al., 2019, A whole-health-economy approach to antimicrobial stewardship: Analysis of current models and future direction, PLoS Medicine, Vol: 16, ISSN: 1549-1277
In a Policy Forum, Alison Holmes and colleagues discuss coordinated approaches to antimicrobial stewardship.
McLeod M, Karampatakis GD, Heyligen L, et al., 2019, The impact of implementing a hospital electronic prescribing and administration system on clinical pharmacists' activities - a mixed methods study, BMC Health Services Research, Vol: 19, Pages: 1-15, ISSN: 1472-6963
BackgroundThe increasing adoption of hospital electronic prescribing and medication administration (ePA) systems has driven a wealth of research around the impact on patient safety. Yet relatively little research has sought to understand the effects on staff, particularly pharmacists. We aimed to investigate the effects of ePA on pharmacists’ activities, including interactions with patients and health professionals, and their perceptions of medication safety risks.MethodsA mixed methods study comprising quantitative direct observations of ward pharmacists before and after implementation of ePA in an English hospital, and semi-structured interviews post-ePA. Quantitative data comprised multi-dimensional work activity sampling to establish the proportion of time ward pharmacists spent on different tasks, with whom and where. These data were extrapolated to estimate task duration. Qualitative interviews with pharmacists explored perceived impact on (i) ward activities, (ii) interactions with patients and different health professionals, (iii) locations where tasks were carried out, and (iv) medication errors.ResultsObservations totalled 116 h and 50 min. Task duration analysis suggested screening inpatient medication increased by 16 mins per 10 patients reviewed (p = 0.002), and searching for paper drug charts or computer decreased by 2 mins per 10 patients reviewed (p = 0.001). Pharmacists mainly worked alone (58% of time pre- and 65% post-ePA, p = 0.17), with patient interactions reducing from 5 to 2% of time (p = 0.03). Seven main themes were identified from the interviews, underpinned by a core explanatory concept around the enhanced and shifting role of the ward pharmacist post-ePA. Pharmacists perceived there to be a number of valuable safety features with ePA. However, paradoxically, some of these may have also inadvertently contributed to medication errors.ConclusionThis study provides quantitative and qualitative
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)
McLeod M, 2015, Measuring Medication Errors, Safety in Medication Use, Editors: Frankllin, Tully, Publisher: CRC Press, ISBN: 9781482227017
The book covers three broad areas: problems in the medication use process, approaches to understanding and resolving them, and putting solutions into practice.
McLeod M, Barber N, Franklin BD, 2015, Facilitators and Barriers to Safe Medication Administration to Hospital Inpatients: A Mixed Methods Study of Nurses' Medication Administration Processes and Systems (the MAPS Study)., PLOS One, Vol: 10, Pages: e0128958-e0128958, ISSN: 1932-6203
CONTEXT: Research has documented the problem of medication administration errors and their causes. However, little is known about how nurses administer medications safely or how existing systems facilitate or hinder medication administration; this represents a missed opportunity for implementation of practical, effective, and low-cost strategies to increase safety. AIM: To identify system factors that facilitate and/or hinder successful medication administration focused on three inter-related areas: nurse practices and workarounds, workflow, and interruptions and distractions. METHODS: We used a mixed-methods ethnographic approach involving observational fieldwork, field notes, participant narratives, photographs, and spaghetti diagrams to identify system factors that facilitate and/or hinder successful medication administration in three inpatient wards, each from a different English NHS trust. We supplemented this with quantitative data on interruptions and distractions among other established medication safety measures. FINDINGS: Overall, 43 nurses on 56 drug rounds were observed. We identified a median of 5.5 interruptions and 9.6 distractions per hour. We identified three interlinked themes that facilitated successful medication administration in some situations but which also acted as barriers in others: (1) system configurations and features, (2) behaviour types among nurses, and (3) patient interactions. Some system configurations and features acted as a physical constraint for parts of the drug round, however some system effects were partly dependent on nurses' inherent behaviour; we grouped these behaviours into 'task focused', and 'patient-interaction focused'. The former contributed to a more streamlined workflow with fewer interruptions while the latter seemed to empower patients to act as a defence barrier against medication errors by being: (1) an active resource of information, (2) a passive information resource, and/or (3) a 'double-checker'. CONCLUS
McLeod M, Ahmed Z, Barber N, et al., 2014, A national survey of inpatient medication systems in English NHS hospitals, BMC HEALTH SERVICES RESEARCH, Vol: 14, ISSN: 1472-6963
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- Citations: 31
Ahmed Z, McLeod MC, Barber N, et al., 2013, The Use and Functionality of Electronic Prescribing Systems in English Acute NHS Trusts: A Cross-Sectional Survey, PLOS ONE, Vol: 8, ISSN: 1932-6203
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- Citations: 24
McLeod MC, Barber N, Franklin BD, 2013, Methodological variations and their effects on reported medication administration error rates, BMJ QUALITY & SAFETY, Vol: 22, Pages: 278-289, ISSN: 2044-5415
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- Citations: 81
McLeod M, Zochowska A, Leonard D, et al., 2012, Comparing the upper limb disorder risks associated with manual and automated cytotoxic compounding: a pilot study, EUROPEAN JOURNAL OF HOSPITAL PHARMACY-SCIENCE AND PRACTICE, Vol: 19, Pages: 293-298, ISSN: 2047-9956
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- Citations: 4
Reynolds M, Vasilakis C, McLeod M, et al., 2011, Using discrete event simulation to design a more efficient hospital pharmacy for outpatients, HEALTH CARE MANAGEMENT SCIENCE, Vol: 14, Pages: 223-236, ISSN: 1386-9620
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- Citations: 39
Franklin BD, McLeod M, Barber N, 2010, Comment on 'Prevalence, Incidence and Nature of Prescribing Errors in Hospital Inpatients: A Systematic Review', DRUG SAFETY, Vol: 33, Pages: 163-165, ISSN: 0114-5916
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- Citations: 5
Reynolds M, McLeod M, Mounsey A, et al., 2010, A simulation study of two hospital pharmacy dispensary systems, Pages: 266-268
In this paper we present the preliminary findings of a discrete event simulation study of two hospital pharmacy dispensary systems. In close collaboration with service managers and other pharmacists, we studied the out-patient prescription dispensing systems of Charing Cross and Hammersmith Hospitals, both part of Imperial College Healthcare NHS Trust. Having established the face validity of the model, we estimated the likely impact of changes in prescription workload in terms of mean turnaround times and proportion of prescriptions completed within 45 minutes. Finally, we sought to investigate the likely impact on the same metrics of removing the strict first-in first-out policy of handing out prescriptions to patients in one of the two hospitals. Contrary to expectations, the simulations suggest that removing such rule will most likely not result in a markedly improved service performance.
Harvey EJ, McLeod M, De Brún C, et al., Criteria to Achieve Safe Antimicrobial Intravenous-to-Oral Switch in Hospitalised Adult Populations: A Systematic Rapid Review
<jats:title>Abstract</jats:title><jats:sec><jats:title>Introduction</jats:title><jats:p>Antimicrobial stewardship and patient safety strategies include early intravenous-to-oral switch (IVOS) for antimicrobials.</jats:p></jats:sec><jats:sec><jats:title>Aim</jats:title><jats:p>This rapid review aimed to assess and collate IVOS criteria from the literature to achieve safe and effective antimicrobial IVOS in the hospital inpatient adult population.</jats:p></jats:sec><jats:sec><jats:title>Method</jats:title><jats:p>The rapid review follows the PRISMA statement and is registered with PROSPERO. Systematic literature searches were conducted. Articles of adult populations published between 2017-2021 were included. IVOS criteria from UK hospital IVOS policies were categorised to inform the framework synthesis of the literature criteria.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>IVOS criteria from 45/164 (27%) UK IVOS policies were categorised into a 5-section framework: 1-Timing of IV antimicrobial review, 2-Clinical signs and symptoms, 3-Infection markers, 4-Enteral route, and 5-Infection exclusions. The literature search identified 477 papers, of which 16 were included. The most common timing for review was 48-72 hours from initiation of intravenous antimicrobial (n=5, 30%). Nine studies (56%) stated clinical signs and symptoms must be improving. Temperature was the most frequently mentioned infection marker (n=14, 88%). Endocarditis had the highest mention as an infection exclusion (n=12, 75%). Overall, 33 IVOS criteria were identified to go forward into the Delphi process.</jats:p></jats:sec><jats:sec><jats:title>Conclusion</jats:title><jats:p>Through the rapid review, 33 IVOS criteria were collated and presented within 5 distinct and comprehensive sections. The lite
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