Implementing interventions to reduce antibiotic use: a qualitative study in high-prescribing practices.

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 antibiotic use. Attention should also focus on the many ambiguities (concerns and questions) about, and contextual barriers to, using these strategies that need addressing to support wider and more consistent implementation

Implementing antibiotic stewardship in high prescribing English general practices: a mixed-methods study

Background Trials have identified antimicrobial stewardship (AMS) strategies that effectively reduce antibiotic use in primary care. However, many are not commonly used in England. The authors co-developed an implementation intervention to improve use of three AMS strategies: enhanced communication strategies, delayed prescriptions, and point-of-care C-reactive protein tests (POC-CRPTs). 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’. Method Routinely collected prescribing data were compared between the intervention and the control practices. 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 the opportunity to conduct implementation tasks. Champions in five practices initiated changes to encourage use of at least one AMS strategy, mostly POC-CRPTs; one practice chose all three. POC-CRPTs was used more when allocated to one person. Conclusion Clinicians need detailed information on exactly how to adopt AMS strategies. 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 suboptimal use

Paleocene methane seep and wood-fall marine environments from Spitsbergen, Svalbard

A recently discovered Paleocene seep locality from Fossildalen on Spitsbergen, Svalbard, is described. This is one of a very few seep communities of the latest Cretaceous–earliest Palaeogene age, and the best preserved Paleocene seep community known so far. The seep carbonates and associated fossils have been first identified in museum collections, and subsequently sampled in the field. The carbonates are exclusively ex-situ and come from the offshore siltstones of the Basilika Formation. Isotopically light composition (δ13C values approaching -50‰ V-PDB), and characteristic petrographic textures of the carbonates combined with the isotopically light archaeal lipid are consistent with the formation at fossil hydrocarbon seep. The invertebrate fauna associated with the carbonates is of moderate diversity (16 species) and has a shallow water affinity. It contains a species of the thyasirid genus Conchocele, common in other seeps of that age. The finding sheds new light onto the history of seepage on Svalbard, and onto the evolution and ecology of seep faunas during the latest Cretaceous–earliest Palaeogene time interval

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Impact of the covid-19 pandemic on community antibiotic prescribing and stewardship: a qualitative interview study with general practitioners in England

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

Tephrostratigraphy of a Lateglacial lake sediment at Wegliny, southwest Poland

This paper presents the first late Quaternary locality in the present-day territories of Poland where multiple cryptotephra layers have been identified. Located near W?gliny in southwest Poland, study of the Lateglacial gyttja deposits reveals the presence of at least four non-visible tephra horizons. Electron microprobe and laser-ablation ICPMS analysis of glass shards suggests products from at least two Icelandic volcanic centres: Katla and Snæsfellsness. Of particular importance is the discovery of two eruptions believed to originate from the east Eifel volcanic field within the Allerød chronozone. One correlates with the well documented Laacher See Tephra (LST) but the second horizon, herein designated T642/T655 would appear to represent an earlier precursor eruption. The chemical composition of the LST and the precursor tephra both appear to match to the Upper Laacher See Tephra (ULST) phase, which previously was thought to have dispersed not to the northeast but in a southerly direction, towards the Alpine foreland. This indicates the eruption dynamics of the Laacher See are more complex than hitherto recognised