Antimicrobial stewardship in the management of sepsis in maternity hospitals - a mixed methodology study

Background: Sepsis is one of the leading causes of maternal mortality and morbidity. The absence of a clear diagnostic marker challenges the process of starting antibiotic therapy. Early identification and management of sepsis is essential. Thus, the sepsis six care bundle (SSCB) was introduced in the UK to improve the care of sepsis patients.;Aim: To evaluate assessment of sepsis and subsequent management including the antibiotic therapy prescribed, and to use this data as a basis of antimicrobial stewardship programme (AMSP) and quality improvement plan within maternity units.;Methods: This study was conducted within three maternity units of NHS Greater Glasgow & Clyde using a mixed methodological approach of an initial quantitative study supplemented by a qualitative study, followed by a quality improvement for further service improvement.;Results: Sepsis was diagnosed in 3% (n=89/2690) of women. There was an inconsistent clinical application of SIRS criteria to inform diagnosis. No causative pathogen was isolated from 60% of clinical specimens. Antibiotic therapy was justified in only 31 women with positive culture results. There was a limited application of AMSPs in the maternity units and midwives did not make a positive contribution, and had a low clinical threshold for initiating therapy. Only 37.1% of the 89 women diagnosed with sepsis had the identifiable SSCB sticker prominently displayed on their medical notes.;Interview findings indicate that this resulted from the absence of implementation strategies, the challenge of diagnosing sepsis and sub-optimal evaluation and review of patients post-diagnosis.;Conclusion: A specialized SSCB specifically for the obstetric population with the full contribution of the multidisciplinary team needs to be developed. Given midwives' central involvement in initial diagnosis, ongoing patient monitoring and antibiotic administration, a more midwife-centred approach to reviewing treatment is a promising way to develop AMSPs in maternity wards.Background: Sepsis is one of the leading causes of maternal mortality and morbidity. The absence of a clear diagnostic marker challenges the process of starting antibiotic therapy. Early identification and management of sepsis is essential. Thus, the sepsis six care bundle (SSCB) was introduced in the UK to improve the care of sepsis patients.;Aim: To evaluate assessment of sepsis and subsequent management including the antibiotic therapy prescribed, and to use this data as a basis of antimicrobial stewardship programme (AMSP) and quality improvement plan within maternity units.;Methods: This study was conducted within three maternity units of NHS Greater Glasgow & Clyde using a mixed methodological approach of an initial quantitative study supplemented by a qualitative study, followed by a quality improvement for further service improvement.;Results: Sepsis was diagnosed in 3% (n=89/2690) of women. There was an inconsistent clinical application of SIRS criteria to inform diagnosis. No causative pathogen was isolated from 60% of clinical specimens. Antibiotic therapy was justified in only 31 women with positive culture results. There was a limited application of AMSPs in the maternity units and midwives did not make a positive contribution, and had a low clinical threshold for initiating therapy. Only 37.1% of the 89 women diagnosed with sepsis had the identifiable SSCB sticker prominently displayed on their medical notes.;Interview findings indicate that this resulted from the absence of implementation strategies, the challenge of diagnosing sepsis and sub-optimal evaluation and review of patients post-diagnosis.;Conclusion: A specialized SSCB specifically for the obstetric population with the full contribution of the multidisciplinary team needs to be developed. Given midwives' central involvement in initial diagnosis, ongoing patient monitoring and antibiotic administration, a more midwife-centred approach to reviewing treatment is a promising way to develop AMSPs in maternity wards

An Observational Cohort Study Evaluating Antimicrobial Use in Peripartum Sepsis : A Tendency towards Overdiagnosis?

Funding: This research received no external funding. This study was sponsored by the University of Strathclyde. Nouf Abutheraa received a financial scholarship from the government of the Kingdom of Saudi Arabia as part of her PhD studentship. The funding source had no involvement or influence on study design, data collection, analysis and interpretation or writing the report. Acknowledgments: The authors thank the healthcare staff who provided general support throughout the study.Peer reviewedPublisher PD

Sepsis scoring systems and use of the Sepsis six care bundle in maternity hospitals

Acknowledgements The authors are grateful for the assistance of healthcare staff who helped to identify septic patients throughout the study. Funding This study was sponsored by University of Strathclyde. Nouf Abutheraa received a financial scholarship funded by the Kingdom of Saudi Arabia government as part of her PhD studentship. The funding body had no role in the design of the study, the collection of the data, the analysis of findings, the interpretation of data or in the writing of this manuscript.Peer reviewedPublisher PD

A Qualitative Study Investigating the Barriers to the Implementation of the ‘Sepsis Six Care Bundle’ in Maternity Wards

Funding: This research received no external funding. Acknowledgments: We thank the healthcare staff who provided general support throughout the study. We are grateful to the research team in the Strathclyde Institute of Pharmacy and Biomedical Science for their contribution in the validation and review of this manuscript.Peer reviewedPublisher PD

A systematic review and narrative synthesis of pharmacist-led education-based antimicrobial stewardship interventions and their effect on antimicrobial use in hospital inpatients

Acknowledgements The authors would like to thank Dr Peerawat Jinathongthai and Dr Sisira Donsamak (Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Ubon Ratchathani University, Thailand) who advised and contributed in the literature search. Funding TM has received the Royal Thai Government Scholarship for his doctoral study (scholarship number ST G5397) at The University of Bath, Bath, UK. None of the other authors were funded by a specific grant for this research from any funding agency in the public, commercial, or non-for-profit sectors.Peer reviewedPostprin

Validity of pneumonia severity assessment scores in low- and middle-income countries : a systematic review and meta-analysis

Background Several pneumonia severity assessment scoring systems have been developed, but the evidence of their utilisation in low- and middle-income countries (LMICs) remains limited. We sought to systematically investigate the evidence around the validity and performance of the existing pneumonia severity scores in adult patients diagnosed with community-acquired pneumonia in LMICs. Methods Medline (Ovid), Embase (Ovid), Cochrane Central Register of Controlled Trials, Scopus, and Web of Science were searched for eligible articles up to May 2020. Pooled estimates of the severity scores performance (sensitivity, specificity) at their high-risk cutoffs in predicting the reported outcome were estimated using the bivariate meta-analysis model. Heterogeneity was assessed using the I² index. Results Overall, 11 were eligible, of which, only six studies with sufficient data were included in the final meta-analysis that involved examining CURB-65 and CRB-65 scores. Both scores at a threshold ≥3 were related to an increased mortality risk, with pooled relative risks of 8.58 (95%CI: 3.48-21.18) and 4.83 (95%CI: 2.52-9.28) for CURB-65 and CRB-65, respectively. The predictive performance of CURB-65 and CRB-65 at their high-risk cutoffs, respectively, were as follows: the pooled sensitivity, 0.69 (95%CI: 0.25-0.94) and 0.04 (95%CI: 0.00-0.40); the pooled specificity, 0.89 (95%CI: 0.72-0.96) and 0.99 (95%C%: 0.95-1.00); and the area under the summary receiver operator characteristic curves, 0.90 (95%CI: 0.87-0.92) and 0.86 (95%CI: 0.83-0.89). Conclusion CURB-65 and CRB-65 at a cutoff ≥3 are strongly associated with mortality and appear to be valid scores for mortality prediction in LMICs. CURB-65 exhibited higher sensitivity and overall accuracy, compared to CRB-65

Validity of Pneumonia Severity Assessment Scores in Africa and South Asia : A Systematic Review and Meta-Analysis

Funding This research received no external funding.Peer reviewedPublisher PD

Validity of pneumonia severity assessment scores in africa and south asia:A systematic review and meta-analysis

Background: Although community-acquired pneumonia (CAP) severity assessment scores are widely used, their validity in low-and middle-income countries (LMICs) is not well defined. We aimed to investigate the validity and performance of the existing scores among adults in LMICs (Africa and South Asia).Methods: Medline, Embase, Cochrane Central Register of Controlled Trials, Scopus and Web of Science were searched to 21 May 2020. Studies evaluating a pneumonia severity score/tool among adults in these countries were included. A bivariate random-effects meta-analysis was performed to examine the scores’ performance in predicting mortality.Results: Of 9900 records, 11 studies were eligible, covering 12 tools. Only CURB-65 (Confusion, Urea, Respiratory Rate, Blood Pressure, Age ≥ 65 years) and CRB-65 (Confusion, Respiratory Rate, Blood Pressure, Age ≥ 65 years) were included in the meta-analysis. Both scores were effective in predicting mortality risk. Performance characteristics (with 95% Confidence Interval (CI)) at high (CURB-65 ≥ 3, CRB-65 ≥ 3) and intermediate-risk (CURB-65 ≥ 2, CRB-65 ≥ 1) cut-offs were as follows: pooled sensitivity, for CURB-65, 0.70 (95% CI = 0.25–0.94) and 0.96 (95% CI = 0.49–1.00), and for CRB-65, 0.09 (95% CI = 0.01–0.48) and 0.93 (95% CI = 0.50–0.99); pooled specificity, for CURB-65, 0.90 (95% CI = 0.73–0.96) and 0.64 (95% CI = 0.45–0.79), and for CRB-65, 0.99 (95% CI = 0.95–1.00) and 0.43 (95% CI = 0.24–0.64).Conclusions: CURB-65 and CRB-65 appear to be valid for predicting mortality in LMICs. CRB-65 may be employed where urea levels are unavailable. There is a lack of robust evidence regarding other scores, including the Pneumonia Severity Index (PSI).</p

The JAK2V617F mutation and the role of therapeutic agents in alleviating myeloproliferative neoplasm symptom burden

Funding information: MPNVoice,Grant/AwardNumber:0001 Acknowledgements: The authors would like to express gratitude to the participants who gave their time to take part in the MOSAICC pilot study. We would also like to acknowledge the work of the charity MPN Voice (grant number 0001), formerly MPD Voice, who kindly funded the work of the MOSAICC pilot study. Finally, we would like to thank Dr Barry Crouch from the University of Aberdeen Digital Research Service, whose knowledge and assistance in coding and statistical software were fundamental to the completion of this research.Peer reviewe

Audit and feedback interventions involving pharmacists to influence prescribing behaviour in general practice : a systematic review and meta-analysis

Introduction Pharmacists, as experts in medicines, are increasingly employed in general practices and undertake a range of responsibilities. Audit and feedback (A&F) interventions are effective in achieving behaviour change, including prescribing. The extent of pharmacist involvement in A&F interventions to influence prescribing is unknown. This review aimed to assess the effectiveness of A&F interventions involving pharmacists on prescribing in general practice compared with no A&F/usual care and to describe features of A&F interventions and pharmacist characteristics. Methods Electronic databases (MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, (Social) Science Citation Indexes, ISI Web of Science) were searched (2012, 2019, 2020). Cochrane systematic review methods were applied to trial identification, selection, and risk of bias. Results were summarized descriptively and heterogeneity was assessed. A random-effects meta-analysis was conducted where studies were sufficiently homogenous in design and outcome. Results Eleven cluster-randomized studies from 9 countries were included. Risk of bias across most domains was low. Interventions focussed on older patients, specific clinical area(s), or specific medications. Meta-analysis of 6 studies showed improved prescribing outcomes (pooled risk ratio: 0.78, 95% confidence interval: 0.64–0.94). Interventions including both verbal and written feedback or computerized decision support for prescribers were more effective. Pharmacists who received study-specific training, provided ongoing support to prescribers or reviewed prescribing for individual patients, contributed to more effective interventions. Conclusions A&F interventions involving pharmacists can lead to small improvements in evidence-based prescribing in general practice settings. Future implementation of A&F within general practice should compare different ways of involving pharmacists to determine how to optimize effectiveness. PRISMA-compliant abstract included in Supplementary Material 1