A needs assessment study for optimising prescribing practice in secondary care junior doctors: the Antibiotic Prescribing Education among Doctors (APED).

BACKGROUND: Appropriate antimicrobial prescribing is essential for patient care, yet up to half of antimicrobial prescriptions written in the UK are sub-optimal. Improving prescriber education has recently been promoted as a mechanism to optimise antimicrobial use, but identification of key learning objectives to facilitate this is so far lacking. Using qualitative methods we investigated junior doctor knowledge, attitudes, and behaviours around antimicrobial prescribing to identify key areas to address in future educational programmes. METHODS: A cross-sectional survey of qualified doctors in training in West London was undertaken exploring antimicrobial prescribing practices and educational needs. RESULTS: Among 140 junior doctors from 5 London hospitals, a third (34 %) reported prescribing primarily unsupervised, and two thirds (67 %) reported difficulties obtaining prescribing support outside of hours. 20 % stated not feeling confident in writing an antimicrobial prescription, but confidence was increased through having confirmatory diagnostic results (24) and obtaining advice from a senior doctor (26 %); whether this senior was from their own specialty, or an infection-specialist, varied significantly (p < 0.01) by experience. Only a small percentage (5-13 %; depending on number of years post-qualification) of participants stated their previous antimicrobial education was effective. 60 % of those in their first year post qualification reported wanting further education in antimicrobial prescribing, rising to 74 % among more experienced junior doctors. Specific areas of educational need identified were (i) principles of antimicrobial prescribing, (ii) diagnosis of infections, (iii) clinical review of patients with infections, (iv) prescribing in the context of antimicrobial resistance, and (v) laboratory testing and test results. CONCLUSIONS: A significant proportion of junior doctors report lone prescribing of antimicrobials in the context of low self-perceived confidence and knowledge in this field, and frequent difficulty in accessing help when necessary. Innovative training, targeting five specific areas identified through this needs assessment, is urgently needed by junior doctors practising in secondary care

Structural basis for the reduced affinity of mfH with fHbp.

<p>(<b>A</b>) Cartoon of hfH₆₇ viewed from through V1 fHbp (solid line) with amino acids changed in hfH with murine residues (outlined by yellow dashes), and those replaced in mfH with human residues (outlined by light blue dashes). (<b>B</b>) SPR analysis of binding of two hfH₆₇ mutants each containing two amino acid changes (shown) with fHbps from each variant family. (<b>C</b>) Far western analysis of V1 fHbp and a control protein, PPX; blots were overlaid with 5 µg/ml of the recombinant proteins mfH, modified mfH (with 14 humanised amino acids) or hfH, or with human serum (1 in 2000 dilution) as indicated; the sizes of the mol. wt. marker are shown. (<b>D</b>) Structure of mfH₆₇ (blue ribbon) superimposed on V1 fHbp (white ribbon) and hfH (green ribbon). While fH₆ from both species are superimposable, the orientation of fH₇ differs significantly between mfH and hfH (indicated in red dashed circle).</p

Non-functional fHbps retain their immunogenicity in transgenic mice.

<p>(<b>A</b>) ELISAs assaying anti-V1 titres elicited in pooled sera following immunisation of transgenic mice with the wild-type protein and non-functional V1 fHbps. (<b>B</b>) SBA titres of sera from individual mice immunisation with fHbps.</p

Effect of mutations at positions equivalent to fHbp V1 residues 283 and 304 (<i>i.e.</i> Thr³⁰⁴ in V2 and V3 fHbp) on the <i>K</i>_D for binding to fH₆₇, shown relative to the wild-type proteins.

<p>DM indicates double Ala substitution; ND, not determined.</p