The first 5 years of Helicobacter pylori research—With an emphasis on the United Kingdom

In the 1970s, 1% of the UK population consulted with dyspepsia; fiberoptic gastroscopy allowed biopsy specimens under direct vision enabling systematic histopathology. Steer et al described clusters of flagellated bacteria closely apposed to the gastric epithelium associated with chronic active gastritis. The first UK series of Helicobacter pylori following Marshall's 1983 visit to Worcester confirmed the association of H. pylori with gastritis. UK researchers completed much early helicobacter research as there were many UK campylobacteriologists. Steer and Newell proved the Campylobacter‐like organisms grown on culture were the same as those seen in the gastric mucosa using antiserum raised by inoculating rabbits with H. pylori from cultures. Wyatt, Rathbone, and others showed a strong correlation between the number of organisms, type and severity of acute gastritis, immunological response, and bacterial adhesion similar to enteropathogenic E coli. Seroprevalence studies indicated H. pylori increased with age. Histopathologists also showed peptic duodenitis was in effect “gastritis in the duodenum” caused by H. pylori, unifying its role in the pathogenesis of both gastritis and duodenal ulceration. These bacteria were initially called Campylobacter pyloridis and then C. pylori. However, electron microscopy suggested that the bacteria were not campylobacters, and this was supported by differences in fatty acid and polyacrylamide electrophoresis profiles. In‐vitro tests indicated that H. pylori was susceptible to penicillins, erythromycin, and quinolones, but not trimethoprim or cefsulodin allowing development of selective media for culture. Monotherapy with erythromycin ethylsuccinate was ineffective, and patients treated with bismuth subsalicylate initially responded with clearance of H. pylori and the associated gastritis, but then many relapsed. Thus, pharmacokinetic and treatment studies were important to direct suitable dual and triple treatments. Work optimized serology, and the rapid biopsy urease and urea breath tests. The link between H.pylori and gastric cancer was established in large seroprevalence studies, and H. pylori test and treat for dyspepsia became routine

Treatment of infections caused by multidrug-resistant Gram-negative bacteria:Report of the British Society for Antimicrobial Chemotherapy/Healthcare Infection Society/British Infection Association Joint Working Party

The Working Party makes more than 100 tabulated recommendations in antimicrobial prescribing for the treatment of infections caused by multidrug-resistant (MDR) Gram-negative bacteria (GNB) and suggest further research, and algorithms for hospital and community antimicrobial usage in urinary infection. The international definition of MDR is complex, unsatisfactory and hinders the setting and monitoring of improvement programmes. We give a new definition of multiresistance. The background information on the mechanisms, global spread and UK prevalence of antibiotic prescribing and resistance has been systematically reviewed. The treatment options available in hospitals using intravenous antibiotics and in primary care using oral agents have been reviewed, ending with a consideration of antibiotic stewardship and recommendations. The guidance has been derived from current peer-reviewed publications and expert opinion with open consultation. Methods for systematic review were NICE compliant and in accordance with the SIGN 50 Handbook; critical appraisal was applied using AGREE II. Published guidelines were used as part of the evidence base and to support expert consensus. The guidance includes recommendations for stakeholders (including prescribers) and antibiotic-specific recommendations. The clinical efficacy of different agents is critically reviewed. We found there are very few good-quality comparative randomized clinical trials to support treatment regimens, particularly for licensed older agents. Susceptibility testing of MDR GNB causing infection to guide treatment needs critical enhancements. Meropenem- or imipenem-resistant Enterobacteriaceae should have their carbapenem MICs tested urgently, and any carbapenemase class should be identified: mandatory reporting of these isolates from all anatomical sites and specimens would improve risk assessments. Broth microdilution methods should be adopted for colistin susceptibility testing. Antimicrobial stewardship programmes should be instituted in all care settings, based on resistance rates and audit of compliance with guidelines, but should be augmented by improved surveillance of outcome in Gram-negative bacteraemia, and feedback to prescribers. Local and national surveillance of antibiotic use, resistance and outcomes should be supported and antibiotic prescribing guidelines should be informed by these data. The diagnosis and treatment of both presumptive and confirmed cases of infection by GNB should be improved. This guidance, with infection control to arrest increases in MDR, should be used to improve the outcome of infections with such strains. Anticipated users include medical, scientific, nursing, antimicrobial pharmacy and paramedical staff where they can be adapted for local use

Duration of antibiotic treatment for common infections in English primary care: cross sectional analysis and comparison with guidelines

Objectives: To evaluate antibiotic therapy durations for common infections in English primary care and to compare this with guidelines. Design: Cross-sectional study. Setting: General practices contributing to The Health Improvement Network database, 2013-2015. Participants: 931,015 consultations that resulted in an antibiotic prescription for one of the following indications: acute sinusitis, acute sore throat, acute cough and bronchitis, pneumonia, acute exacerbation of chronic obstructive pulmonary disease (COPD), acute otitis media, acute cystitis, prostatitis, pyelonephritis, cellulitis, impetigo, scarlet fever and gastroenteritis. Main outcome measures: The main outcomes were the percentage of antibiotic prescriptions with a duration exceeding the guideline recommendation and the total number of days beyond the recommended duration for each indication. Results: The most common reasons for the prescriptions were patients consulting with acute bronchitis and cough (386,972), acute sore throat (239,231), acute otitis media (83,054), and acute sinusitis (76,683). Antibiotic treatments for upper respiratory indications and acute bronchitis accounted for more than two thirds of the total prescriptions considered, and ≥80% of these treatment courses exceeded guideline recommendations. Notable exceptions were acute sinusitis, where only 9.6% (95% CI 9.4 to 9.9%) of prescriptions exceeded 7 days and acute sore throat where only 2.1% (95% CI 2.0 to 2.1) exceed 10 days (recent guidance recommends 5 days). More than half of antibiotic prescriptions were longer than guidelines recommend for acute cystitis among females (54.6%, 95% CI 54.1 to 55.0%). The percentage of antibiotic prescriptions exceeding the recommended duration was lower for most non-respiratory infections. For the 931,015 included consultations resulting in antibiotic prescriptions, approximately 1.3 million days were beyond the durations recommended by the guidelines. Conclusion: For most common infections treated in primary care, a substantial proportion of antibiotic prescriptions have durations exceeding those recommended in guidelines. Substantial reductions in antibiotic exposure can be accomplished by aligning antibiotic prescription durations with guidelines

Teacher and student views on the feasibility of peer to peer education as a model to educate 16–18 year olds on prudent antibiotic use—a qualitative study

Peer education (PE) has been used successfully to improve young peoples’ health-related behaviour. This paper describes a qualitative evaluation of the feasibility of university healthcare students delivering PE, covering self-care and antibiotic use for infections, to biology students in three UK schools (16–18 years), who then educated their peers. Twenty peer educators (PEds) participated in focus groups and two teachers took part in interviews to discuss PE feasibility. Data were analysed inductively. All participants reported that teaching students about antibiotic resistance was important. PE was used by PEds to gain communication skills and experience for their CV. PEds confidence increased with practice and group delivery. Interactive activities and real-life illness scenarios facilitated enjoyment. Barriers to PE were competing school priorities, no antibiotic content in the non-biology curriculum, controlling disruptive behaviour, and evaluation consent and questionnaire completion. Participation increased PEds’ awareness of appropriate antibiotic use. This qualitative study supports the feasibility of delivering PE in schools. Maximising interactive and illness scenario content, greater training and support for PEds, and inclusion of infection self-care and antibiotics in the national curriculum for all 16–18-year olds could help facilitate greater antibiotic education in schools. Simplifying consent and data collection procedures would facilitate future evaluations

Alternative approaches to managing respiratory tract infections: a survey of public perceptions

Background Respiratory tract infections (RTIs) are a common reason for people to consult in primary care, and contribute to antibiotic overuse and antimicrobial resistance (AMR). Alternative approaches to supporting patients with RTIs may help, but it is important to understand public perceptions about these approaches before they are widely implemented. Aim To describe public perceptions regarding finger-prick testing, back-up antibiotic prescriptions (BUPs), and alternatives to traditional consultations for RTIs, and identify factors associated with favouring these approaches. Design & setting Online national survey (HealthWise Wales) with linked primary care health record data. Method Survey item response distributions were described. Associations between responses about consultation alternatives, BUP, and finger-prick point-of-care testing (POCT), and potential explanatory variables, were explored using logistic regression. Results A total of 8752 participants completed the survey between 2016 and 2018. The survey found 76.7% (n = 3807/4,966) and 71.2% (n = 3529/4,953) of responders with valid responses were in favour of being able to consult with a pharmacist or nurse in their GP surgery, or with a community pharmacist, respectively. It also showed 92.8% (n = 8034/8659) of responders indicated they would be happy to have a finger-prick test to guide antibiotic prescribing, and 31.8% (n = 2746/8646) indicated they would like to be given a BUP if their clinician thought immediate antibiotics were not required. In addition, 47.4% (n = 2342/4944) and 42.3% (n = 2095/4949) were in favour of having video and email consultations, respectively. Characteristics associated with different response options were identified. Conclusion Consulting with pharmacists, using electronic communication tools, and finger-prick testing are widely acceptable approaches. BUP was described as acceptable less often, and is likely to require greater information and support when used

Improving management of respiratory tract infections in community pharmacies and promoting antimicrobial stewardship: a cluster randomised control trial with a self-report behavioural questionnaire and process evaluation

In England, 81% of all antibiotic prescriptions originate in primary care/community settings, of which up to 20% are thought to be inappropriate. Community pharmacies are often the first point of community contact for patients with suspected infections; providing an opportunity for community pharmacy teams to promote antimicrobial stewardship (AMS). The objective of the study was to improve the management of infections and antimicrobial stewardship in community pharmacies. The study methodology included a non-blinded cluster randomised control trial with pharmacy staff in 272 community pharmacies in England. The intervention arm received an AMS webinar and a patient facing respiratory tract infection (RTI) leaflet (TARGET TYI-RTI) for use in everyday practice for four weeks. The control arm received a webinar on how to participate in the study. The primary outcome was self-reported referrals to general practitioners (GPs). The secondary outcomes were; provision of self-care advice/ written information to patients, referrals to pharmacists, sign-posting to non-prescription medicines and common barriers and facilitators to advice-giving in community pharmacies. Ethics approval was granted by the Public Health England Research Ethics and Governance Group. 66.91% (182 of 272) of pharmacies provided 3649 patient consultation data reports across both arms. Use of the leaflet was associated with a lower likelihood of referrals to GPs for certain RTIs (p < 0.05) and a more frequent provision of self-care advice than the control (p = 0.06). Opportunities to deliver self-care advice were limited due to lack of time. Pharmacy staff had good motivation and capability for managing self-limiting infections but the opportunity to do so was a perceived barrier. Use of the TARGET leaflet facilitated pharmacy staff to give more self-care advice and decreased referrals to GPs

Peer-education as a tool to educate on antibiotics, resistance and use in 16–18-year-olds: A feasibility study

© 2020 by the authors. Licensee MDPI, Basel, Switzerland. Peer education (PE) interventions may help improve knowledge and appropriate use of antibiotics in young adults. In this feasibility study, health-care students were trained to educate 16–18 years old biology students, who then educated their non-biology peers, using e-Bug antibiotic lessons. Knowledge was assessed by questionnaires, and antibiotic use by questionnaire, SMS messaging and GP record searches. Five of 17 schools approached participated (3 PE and 2 control (usual lessons)). 59% (10/17) of university students and 28% (15/54) of biology students volunteered as peer-educators. PE was well-received; 30% (38/127) intervention students and 55% (66/120) control students completed all questionnaires. Antibiotic use from GP medical records (54/136, 40% of students’ data available), student SMS (69/136, 51% replied) and questionnaire (109/136, 80% completed) data showed good agreement between GP and SMS (kappa = 0.72), but poor agreement between GP and questionnaires (kappa = 0.06). Median knowledge scores were higher post-intervention, with greater improvement for non-biology students. Delivering and evaluating e-Bug PE is feasible with supportive school staff. Single tiered PE by university students may be easier to regulate and manage due to time constraints on school students. SMS collection of antibiotic data is easier and has similar accuracy to GP data

Increasing chlamydia screening tests in general practice: A modi fied Zelen prospective cluster randomised controlled trial evaluating a complex intervention based on the theory of planned behaviour

Objective: To determine if a structured complex intervention increases opportunistic chlamydia screening testing of patients aged 15-24 years attending English general practitioner (GP) practices. Methods: A prospective, Cluster Randomised Controlled Trial with a modified Zelen design involving 160 practices in South West England in 2010. The intervention was based on the Theory of Planned Behaviour (TPB). It comprised of practice-based education with up to two additional contacts to increase the importance of screening to GP staff and their confidence to offer tests through skill development (including videos). Practical resources (targets, posters, invitation cards, computer reminders, newsletters including feedback) aimed to actively influence social cognitions of staff, increasing their testing intention. Results: Data from 76 intervention and 81 control practices were analysed. In intervention practices, chlamydia screening test rates were 2.43/100 15-24-yearolds registered preintervention, 4.34 during intervention and 3.46 postintervention; controls testing rates were 2.61/ 100 registered patients prior intervention, 3.0 during intervention and 2.82 postintervention. During the intervention period, testing in intervention practices was 1.76 times as great (CI 1.24 to 2.48) as controls; this persisted for 9 months postintervention (1.57 times as great, CI 1.27 to 2.30). Chlamydia infections detected increased in intervention practices from 2.1/1000 registered 15-24-year-olds prior intervention to 2.5 during the intervention compared with 2.0 and 2.3/1000 in controls (Estimated Rate Ratio intervention versus controls 1.4 (CI 1.01 to 1.93). Conclusions: This complex intervention doubled chlamydia screening tests in fully engaged practices. The modified Zelen design gave realistic measures of practice full engagement (63) and efficacy of this educational intervention in general practice; it should be used more often. Trial registration: The trial was registered on the UK Clinical Research Network Study Portfolio database. UKCRN number 9722

Tools to overcome potential barriers to chlamydia screening in general practice: Qualitative evaluation of the implementation of a complex intervention

Background: Chlamydia trachomatis remains a significant public health problem. We used a complex intervention, with general practice staff, consisting of practice based workshops, posters, computer prompts and testing feedback and feedback to increase routine chlamydia screening tests in under 25 year olds in South West England. We aimed to evaluate how intervention components were received by staff and to understand what determined their implementation into ongoing practice. Methods: We used face-to-face and telephone individual interviews with 29 general practice staff analysed thematically within a Normalisation Process Theory Framework which explores: 1. Coherence (if participants understand the purpose of the intervention); 2. Cognitive participation (engagement with and implementation of the intervention); 3. Collective action (work actually undertaken that drives the intervention forwards); 4. Reflexive monitoring (assessment of the impact of the intervention). Results: Our results showed coherence as all staff including receptionists understood the purpose of the training was to make them aware of the value of chlamydia screening tests and how to increase this in their general practice. The training was described by nearly all staff as being of high quality and responsible for creating a shared understanding between staff of how to undertake routine chlamydia screening. Cognitive participation in many general practice staff teams was demonstrated through their engagement by meeting after the training to discuss implementation, which confirmed the role of each staff member and the use of materials. However several participants still felt unable to discuss chlamydia in many consultations or described sexual health as low priority among colleagues. National targets were considered so high for some general practice staff that they didn’t engage with the screening intervention. Collective action work undertaken to drive the intervention included use of computer prompts which helped staff remember to make the offer, testing rate feedback and having a designated lead. Ensuring patients collected samples when still in the general practice was not attained in most general practices. Reflexive monitoring showed positive feedback from patients and other staff about the value of screening, and feedback about the general practices testing rates helped sustain activity. Conclusions: A complex intervention including interactive workshops, materials to help implementation and feedback can help chlamydia screening testing increase in general practices