Assessment of health and science undergraduate students’ knowledge, attitudes, education and training related to antibiotic use and antimicrobial resistance in 27 EU/EEA universities

Introduction. Antimicrobial resistance (AMR) is a complicated public health challenge. This study aimed to obtain a baseline assessment of undergraduate health and science students’ knowledge and attitudes of antibiotic use, resistance and stewardship across European countries and to evaluate education methods. // Methods. A 43-item cross-sectional multilingual survey of healthcare practitioners and undergraduates studying dentistry, medicine, nursing, pharmacy and science subjects was conducted by Public Health England (now UK Health Security Agency) in 2018 across 30 EU/EEA countries. Of the 43 questions developed for healthcare workers, a subset of 33 questions directly relevant to students was available for student completion. // Results. A total of 1,222 students from 27 EU/EEA countries participated in the survey, with 50% studying medicine (379/760). The mean score across seven knowledge questions was 6.04 out of 7 (sd, 1.14). Knowledge scores differed by the degree being studied and were higher among students in the later years of their degree programme. Knowledge was significantly higher (P<0.001) in those who had received training on prudent antibiotic use and infection management. Most students had not heard about AMR awareness campaigns, including European Antibiotic Awareness Day, and felt they did not have a key role in addressing AMR. // Conclusion. Although students demonstrated good overall knowledge of antibiotic use and AMR, many lacked awareness of their role in tackling AMR. Designing more effective targeted educational interventions for these students, such as curriculum development and interprofessional education and training, could be beneficial to support appropriate antibiotic use and efforts to tackle AMR

Challenges of assessing the cost effectiveness of AMR campaigns:Considerations for policy makers

Objectives: To provide overview and understanding of the current challenges in assessing the cost-effectiveness of antimicrobial resistance (AMR) campaigns and highlight the main considerations for policy makers when evaluating existing and future evidence to inform decision making. Study design: Policy commentary. Methods: A rapid review of cost-effectiveness analyses evaluating public AMR campaigns highlighted significant challenges with existing methodologies which were reviewed extensively in further literature searches to inform overview and commentary. Results: Longstanding challenges in measuring clinical outcomes for use in economic evaluations and the methodologies available to health economists to evaluate public health campaigns were identified: Identifying and measuring appropriate outcomes, including broader societal impacts, capturing relevant outcomes which result over longer timescales, and accounting for the costs of AMR. These remain significant obstacles in assessing the true cost-effectiveness of interventions. Conclusions: Little methodological progress has been made in this area over the past 20 years, leaving policy makers in a difficult conundrum when justifying future investment in public campaigns to combat AMR. Evidence of high societal value placed on such interventions suggests future work to establish the cost-effectiveness of public AMR campaigns and support policy making are essential.</p

Public knowledge and attitudes towards antibiotic use across England – pre- and post-pandemic

BackgroundAntibiotic misuse is a major preventable driving factor for antimicrobial resistance (AMR). Most antibiotics are prescribed in primary care where demand for consultations for common self-limiting infections is greatest, meaning public knowledge may influence antibiotic prescribing. This study aims to explore how public knowledge of and attitudes towards antibiotics have changed over time.MethodsIpsos conducted interviews as part of routine surveys across England in 2020, 2021, 2022 and 2024. Random and quota sampling were used to ensure a representative sample. Questionnaire responses were weighted to ensure the results are broadly representative of the population. Pearson's Chi-squared test was used to test for differences in proportions across levels of categorical variables and between responses across the four years.ResultsResponses were obtained from 2,022 (pre-pandemic); 1,676 (pandemic-Y1); 1,663 (pandemic-Y2) and 3,024 (post-pandemic) respondents. The proportion of respondents who felt they had personal responsibility to tackle AMR increased from 57% pre-pandemic to 62% in pandemic-Y1 (p < 0.05), reducing to 46% post-pandemic. The proportion of respondents correctly answering the statement antibiotics will always speed up my recovery from an infection increased from 58% pre-pandemic to 65% in pandemic-Y1 and Y2 (p < 0.05), reducing to 56% post-pandemic. Knowledge regarding the use of antibiotics to treat ear, urine infections and COVID-19 was lowest post-pandemic. Trust in healthcare professionals (HCPs) regarding whether antibiotics are needed peaked during (range: 77% to 91%) and declined post-pandemic (range: 72% to 86%). The proportion of respondents who reported they would be pleased if their GP did not prescribe antibiotics was highest pre-pandemic (84%), decreasing to 65% post-pandemic. The proportion of respondents who were likely to request antibiotics from their GP declined from pre-pandemic (21%) to pandemic-Y1 (19%) but increased post-pandemic (25%). Demographic variations were observed across nearly all questions.ConclusionsThis paper highlights some concerning trends. Knowledge regarding AMR and the specific infections that antibiotics can treat has reverted to pre-pandemic levels, while levels of uncertainty about AMR and antibiotic use have increased. Although high, trust in HCPs has declined. Therefore, future interventions may wish to support HCPs to build trust with their patients and consider how care pathways can promote this

Effects of antiplatelet therapy on stroke risk by brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases: subgroup analyses of the RESTART randomised, open-label trial

Background Findings from the RESTART trial suggest that starting antiplatelet therapy might reduce the risk of recurrent symptomatic intracerebral haemorrhage compared with avoiding antiplatelet therapy. Brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases (such as cerebral microbleeds) are associated with greater risks of recurrent intracerebral haemorrhage. We did subgroup analyses of the RESTART trial to explore whether these brain imaging features modify the effects of antiplatelet therapy

Improving healthcare professionals’ interactions with patients to tackle antimicrobial resistance: a systematic review of interventions, barriers, and facilitators

IntroductionAntimicrobial resistance (AMR) is a major public health threat. With the growing emphasis on patient-centred care/ shared decision making, it is important for healthcare professionals’ (HCPs) who prescribe, dispense, administer and/or monitor antimicrobials to be adequately equipped to facilitate appropriate antimicrobial use. We systematically identified existing interventions which aim to improve HCPs interaction with patients and examined barriers and facilitators of appropriate the use of such interventions and appropriate antimicrobial use among both HCPs and patientsantimicrobial use while using these interventions.MethodsWe searched MEDLINE, EMBASE, Web of Science, Google Scholar, and internet (via Google search engine). We included primary studies, published in English from 2010 to 2023 [PROSPERO (CRD42023395642)]. The protocol was preregistered with PROSPERO (CRD42023395642). We performed quality assessment using mixed methods appraisal tool. We applied narrative synthesis and used the COM-B (Capability, Opportunity, Motivation -Behaviour) as a theoretical framework for barriers and facilitators at HCP and patient levels.ResultsOf 9,172 citations retrieved from database searches, From 4,979 citations remained after removal of duplicates. We included 59 studies spanning over 13 countries. Interventions often involved multiple components beyond HCPs’ interaction with patients. From 24 studies reporting barriers and facilitators, we identified issues relating to capability (such as, knowledge/understanding about AMR, diagnostic uncertainties, awareness of interventions and forgetfulness); opportunity (such as, time constraint and intervention accessibility) and motivation (such as, patient’s desire for antibiotics and fear of litigation).ConclusionThe findings of this review should be considered by intervention designers/adopters and policy makers to improve utilisation and effectiveness

Prenatal alcohol prevention in the UK:mapping the landscape through systematic collaborative review

BackgroundUK policy makers have called for urgent action to reduce prenatal alcohol exposure (PAE), but evidence on what is effective is scarce. We aimed to identify, evaluate, and synthesise evidence on content, process aspects, and effectiveness of UK PAE prevention initiatives.MethodsWe conducted a systematic search of published and grey literature on UK PAE prevention (PROSPERO: CRD42020209460); consultations with 61 academic, practice, policy, third sector, and public stakeholders; and semi-structured 12 interviews with pregnant people (who were aged ≥18 years and ≥12 weeks' gestation) and service providers to discuss experiences of PAE prevention. Participants were purposively sampled to cover each UK region and identified through maternity sites, social media and, for stakeholder consultees, researcher networks. Information from relevant PAE prevention initiatives from the literature was independently extracted by two reviewers. Ethical approval and informed consent were obtained for interviews, which were recorded and transcribed. Qualitative evidence was synthesised using thematic analysis. Quantitative data will be summarised using descriptive statistics and meta-analysis.FindingsWe identified 14 PAE prevention initiatives through literature searches (22 of 4064 results were eligible), stakeholder consultation, and interviews. Initiatives included screening and intervention, campaigns, and education or training. Seven initiatives were identified in the north of England. Two initiatives were identified in Scotland and two in Wales. The East of England, West Midlands, and South East of England had one each. None were identified in Southwest of England or Northern Ireland. Barriers to prevention included absence of resources, excessive workload, concerns around blame, and COVID-19. Enablers included workforce training and trust between pregnant people and service providers. Effectiveness of evidence was scarce.InterpretationKey strengths include extensive searches and multidisciplinary consultation. Data collection and analyses are ongoing and will be finalised before November, 2022. This research will provide a comprehensive analysis of current provision, providing crucial evidence to inform research and practice.FundingThe National Institute for Health and Care Research.ContributorsCM conceived of the study. CM wrote the study protocol with input from LZ, TD, AP, FdV, SB, HC, PC, RL, AM, RM, and DTR. CM designed interview schedules with input from LZ, SB, PC, RL, AM, RM, FdV, and the study public involvement panel. CM and FF conducted participant interviews. CM, LZ, SB, HC, PC, LH, AM, RM, DTR, and OS contributed to the identification of contacts and initiatives. CM, TD, and EG carried out literature searches and data extraction. CM and TD conducted analyses. CM wrote the abstract. All authors have seen and approved the final version of the abstract for publication.Declaration of interestsSB is chief executive of The National Organisation for Fetal Alcohol Spectrum Disorders. She is sometimes paid for providing presentations. This money goes back into the organisation. The National Organisation for Fetal Alcohol Spectrum Disorders accepts funding from the alcohol industry, government, private foundations, and trusts and individuals, but has a strict policy that funders have no influence on substance. PC was an expert contributor to the Department of Health and Social Care's report, ‘Fetal Alcohol Spectrum Disorder: Health Needs Assessment’. She has received funding from the Greater Manchester Health and Social Care Partnership to estimate the prevalence of Fetal Alcohol Spectrum Disorders in Greater Manchester, and from the Medical Research Council to develop an intervention for families affected by Fetal Alcohol Spectrum Disorders. She is an unpaid member of the Steering Board to oversee Greater Manchester's Preventing Alcohol Exposed Pregnancy Programme. RM is an unpaid advisor to various FASD charities and runs the National Clinic for Fetal Alcohol Spectrum Disorders.AcknowledgmentsThe study was funded by The National Institute for Health and Care Research School for Public Health Research Postdoctoral Launching Fellowship/ResNet ECR funding (McQuire). We would like to thank the members of our Public Participation and Involvement panel, who assisted with the design of the interview materials, study information sheets, and consent forms.<br/

Effects of antiplatelet therapy after stroke due to intracerebral haemorrhage (RESTART): a randomised, open-label trial

Background: Antiplatelet therapy reduces the risk of major vascular events for people with occlusive vascular disease, although it might increase the risk of intracranial haemorrhage. Patients surviving the commonest subtype of intracranial haemorrhage, intracerebral haemorrhage, are at risk of both haemorrhagic and occlusive vascular events, but whether antiplatelet therapy can be used safely is unclear. We aimed to estimate the relative and absolute effects of antiplatelet therapy on recurrent intracerebral haemorrhage and whether this risk might exceed any reduction of occlusive vascular events. Methods: The REstart or STop Antithrombotics Randomised Trial (RESTART) was a prospective, randomised, open-label, blinded endpoint, parallel-group trial at 122 hospitals in the UK. We recruited adults (≥18 years) who were taking antithrombotic (antiplatelet or anticoagulant) therapy for the prevention of occlusive vascular disease when they developed intracerebral haemorrhage, discontinued antithrombotic therapy, and survived for 24 h. Computerised randomisation incorporating minimisation allocated participants (1:1) to start or avoid antiplatelet therapy. We followed participants for the primary outcome (recurrent symptomatic intracerebral haemorrhage) for up to 5 years. We analysed data from all randomised participants using Cox proportional hazards regression, adjusted for minimisation covariates. This trial is registered with ISRCTN (number ISRCTN71907627). Findings: Between May 22, 2013, and May 31, 2018, 537 participants were recruited a median of 76 days (IQR 29–146) after intracerebral haemorrhage onset: 268 were assigned to start and 269 (one withdrew) to avoid antiplatelet therapy. Participants were followed for a median of 2·0 years (IQR [1·0– 3·0]; completeness 99·3%). 12 (4%) of 268 participants allocated to antiplatelet therapy had recurrence of intracerebral haemorrhage compared with 23 (9%) of 268 participants allocated to avoid antiplatelet therapy (adjusted hazard ratio 0·51 [95% CI 0·25–1·03]; p=0·060). 18 (7%) participants allocated to antiplatelet therapy experienced major haemorrhagic events compared with 25 (9%) participants allocated to avoid antiplatelet therapy (0·71 [0·39–1·30]; p=0·27), and 39 [15%] participants allocated to antiplatelet therapy had major occlusive vascular events compared with 38 [14%] allocated to avoid antiplatelet therapy (1·02 [0·65–1·60]; p=0·92). Interpretation: These results exclude all but a very modest increase in the risk of recurrent intracerebral haemorrhage with antiplatelet therapy for patients on antithrombotic therapy for the prevention of occlusive vascular disease when they developed intracerebral haemorrhage. The risk of recurrent intracerebral haemorrhage is probably too small to exceed the established benefits of antiplatelet therapy for secondary prevention

Global, regional, and national burden of traumatic brain injury and spinal cord injury, 1990–2016: A systematic analysis for the Global Burden of Disease Study 2016

© 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license Background: Traumatic brain injury (TBI) and spinal cord injury (SCI) are increasingly recognised as global health priorities in view of the preventability of most injuries and the complex and expensive medical care they necessitate. We aimed to measure the incidence, prevalence, and years of life lived with disability (YLDs) for TBI and SCI from all causes of injury in every country, to describe how these measures have changed between 1990 and 2016, and to estimate the proportion of TBI and SCI cases caused by different types of injury. Methods: We used results from the Global Burden of Diseases, Injuries, and Risk Factors (GBD) Study 2016 to measure the global, regional, and national burden of TBI and SCI by age and sex. We measured the incidence and prevalence of all causes of injury requiring medical care in inpatient and outpatient records, literature studies, and survey data. By use of clinical record data, we estimated the proportion of each cause of injury that required medical care that would result in TBI or SCI being considered as the nature of injury. We used literature studies to establish standardised mortality ratios and applied differential equations to convert incidence to prevalence of long-term disability. Finally, we applied GBD disability weights to calculate YLDs. We used a Bayesian meta-regression tool for epidemiological modelling, used cause-specific mortality rates for non-fatal estimation, and adjusted our results for disability experienced with comorbid conditions. We also analysed results on the basis of the Socio-demographic Index, a compound measure of income per capita, education, and fertility. Findings: In 2016, there were 27·08 million (95% uncertainty interval [UI] 24·30–30·30 million) new cases of TBI and 0·93 million (0·78–1·16 million) new cases of SCI, with age-standardised incidence rates of 369 (331–412) per 100 000 population for TBI and 13 (11–16) per 100 000 for SCI. In 2016, the number of prevalent cases of TBI was 55·50 million (53·40–57·62 million) and of SCI was 27·04 million (24·98–30·15 million). From 1990 to 2016, the age-standardised prevalence of TBI increased by 8·4% (95% UI 7·7 to 9·2), whereas that of SCI did not change significantly (−0·2% [–2·1 to 2·7]). Age-standardised incidence rates increased by 3·6% (1·8 to 5·5) for TBI, but did not change significantly for SCI (−3·6% [–7·4 to 4·0]). TBI caused 8·1 million (95% UI 6·0–10·4 million) YLDs and SCI caused 9·5 million (6·7–12·4 million) YLDs in 2016, corresponding to age-standardised rates of 111 (82–141) per 100 000 for TBI and 130 (90–170) per 100 000 for SCI. Falls and road injuries were the leading causes of new cases of TBI and SCI in most regions. Interpretation: TBI and SCI constitute a considerable portion of the global injury burden and are caused primarily by falls and road injuries. The increase in incidence of TBI over time might continue in view of increases in population density, population ageing, and increasing use of motor vehicles, motorcycles, and bicycles. The number of individuals living with SCI is expected to increase in view of population growth, which is concerning because of the specialised care that people with SCI can require. Our study was limited by data sparsity in some regions, and it will be important to invest greater resources in collection of data for TBI and SCI to improve the accuracy of future assessments. Funding: Bill & Melinda Gates Foundation

Effects of antiplatelet therapy after stroke due to intracerebral haemorrhage (RESTART): a randomised, open-label trial

Background: Antiplatelet therapy reduces the risk of major vascular events for people with occlusive vascular disease, although it might increase the risk of intracranial haemorrhage. Patients surviving the commonest subtype of intracranial haemorrhage, intracerebral haemorrhage, are at risk of both haemorrhagic and occlusive vascular events, but whether antiplatelet therapy can be used safely is unclear. We aimed to estimate the relative and absolute effects of antiplatelet therapy on recurrent intracerebral haemorrhage and whether this risk might exceed any reduction of occlusive vascular events. Methods: The REstart or STop Antithrombotics Randomised Trial (RESTART) was a prospective, randomised, open-label, blinded endpoint, parallel-group trial at 122 hospitals in the UK. We recruited adults (≥18 years) who were taking antithrombotic (antiplatelet or anticoagulant) therapy for the prevention of occlusive vascular disease when they developed intracerebral haemorrhage, discontinued antithrombotic therapy, and survived for 24 h. Computerised randomisation incorporating minimisation allocated participants (1:1) to start or avoid antiplatelet therapy. We followed participants for the primary outcome (recurrent symptomatic intracerebral haemorrhage) for up to 5 years. We analysed data from all randomised participants using Cox proportional hazards regression, adjusted for minimisation covariates. This trial is registered with ISRCTN (number ISRCTN71907627). Findings: Between May 22, 2013, and May 31, 2018, 537 participants were recruited a median of 76 days (IQR 29–146) after intracerebral haemorrhage onset: 268 were assigned to start and 269 (one withdrew) to avoid antiplatelet therapy. Participants were followed for a median of 2·0 years (IQR [1·0– 3·0]; completeness 99·3%). 12 (4%) of 268 participants allocated to antiplatelet therapy had recurrence of intracerebral haemorrhage compared with 23 (9%) of 268 participants allocated to avoid antiplatelet therapy (adjusted hazard ratio 0·51 [95% CI 0·25–1·03]; p=0·060). 18 (7%) participants allocated to antiplatelet therapy experienced major haemorrhagic events compared with 25 (9%) participants allocated to avoid antiplatelet therapy (0·71 [0·39–1·30]; p=0·27), and 39 [15%] participants allocated to antiplatelet therapy had major occlusive vascular events compared with 38 [14%] allocated to avoid antiplatelet therapy (1·02 [0·65–1·60]; p=0·92). Interpretation: These results exclude all but a very modest increase in the risk of recurrent intracerebral haemorrhage with antiplatelet therapy for patients on antithrombotic therapy for the prevention of occlusive vascular disease when they developed intracerebral haemorrhage. The risk of recurrent intracerebral haemorrhage is probably too small to exceed the established benefits of antiplatelet therapy for secondary prevention

Effects of antiplatelet therapy after stroke due to intracerebral haemorrhage (RESTART): a randomised, open-label trial

BACKGROUND: Antiplatelet therapy reduces the risk of major vascular events for people with occlusive vascular disease, although it might increase the risk of intracranial haemorrhage. Patients surviving the commonest subtype of intracranial haemorrhage, intracerebral haemorrhage, are at risk of both haemorrhagic and occlusive vascular events, but whether antiplatelet therapy can be used safely is unclear. We aimed to estimate the relative and absolute effects of antiplatelet therapy on recurrent intracerebral haemorrhage and whether this risk might exceed any reduction of occlusive vascular events. METHODS: The REstart or STop Antithrombotics Randomised Trial (RESTART) was a prospective, randomised, open-label, blinded endpoint, parallel-group trial at 122 hospitals in the UK. We recruited adults (≥18 years) who were taking antithrombotic (antiplatelet or anticoagulant) therapy for the prevention of occlusive vascular disease when they developed intracerebral haemorrhage, discontinued antithrombotic therapy, and survived for 24 h. Computerised randomisation incorporating minimisation allocated participants (1:1) to start or avoid antiplatelet therapy. We followed participants for the primary outcome (recurrent symptomatic intracerebral haemorrhage) for up to 5 years. We analysed data from all randomised participants using Cox proportional hazards regression, adjusted for minimisation covariates. This trial is registered with ISRCTN (number ISRCTN71907627). FINDINGS: Between May 22, 2013, and May 31, 2018, 537 participants were recruited a median of 76 days (IQR 29-146) after intracerebral haemorrhage onset: 268 were assigned to start and 269 (one withdrew) to avoid antiplatelet therapy. Participants were followed for a median of 2·0 years (IQR [1·0- 3·0]; completeness 99·3%). 12 (4%) of 268 participants allocated to antiplatelet therapy had recurrence of intracerebral haemorrhage compared with 23 (9%) of 268 participants allocated to avoid antiplatelet therapy (adjusted hazard ratio 0·51 [95% CI 0·25-1·03]; p=0·060). 18 (7%) participants allocated to antiplatelet therapy experienced major haemorrhagic events compared with 25 (9%) participants allocated to avoid antiplatelet therapy (0·71 [0·39-1·30]; p=0·27), and 39 [15%] participants allocated to antiplatelet therapy had major occlusive vascular events compared with 38 [14%] allocated to avoid antiplatelet therapy (1·02 [0·65-1·60]; p=0·92). INTERPRETATION: These results exclude all but a very modest increase in the risk of recurrent intracerebral haemorrhage with antiplatelet therapy for patients on antithrombotic therapy for the prevention of occlusive vascular disease when they developed intracerebral haemorrhage. The risk of recurrent intracerebral haemorrhage is probably too small to exceed the established benefits of antiplatelet therapy for secondary prevention. FUNDING: British Heart Foundation