IMPROVING THE MANAGEMENT OF ASYMPTOMATIC BACTERIURIA IN OLDER ADULTS IN LONG-TERM CARE

Abstract Problem: The unnecessary or inappropriate use of prescription antibiotics is a public health problem. An estimated 40% to 75% of antibiotics prescribed in U.S. nursing homes may be unwarranted, and moreover, the most commonly treated infection in nursing homes is a urinary tract infection (UTI). Up to one-third to one-half of prescriptions used to treat suspected UTIs in nursing home residents are actually aimed at asymptomatic bacteriuria (ASB). Consistent findings show the treatment of ASB is unnecessary and can be harmful, leading to increased rates of Clostridium difficile, multidrug resistant organisms, adverse drug events, hospital admissions, and higher health care costs. The Centers for Disease Control and Prevention (CDC) recommends that all nursing homes take steps to improve antibiotic prescribing practices through the utilization of antibiotic stewardship activities. The CDC defines antibiotic stewardship as a set of commitments and actions designed optimize the treatment of infections while reducing adverse events associated with antibiotic use. Project Aim: The purpose of this quality improvement project was to assess if the implementation of an antibiotic stewardship program in the nursing home setting decreases the rate of antibiotics prescribed for ASB in older adults. Project Method: A retrospective chart review of data was utilized to record baseline rates of antibiotics prescribed for UTIs and ASB. The chart review included the analysis of nursing notes, progress notes, provider visits, and nursing home infection logs to determine if an antibiotic was prescribed for a symptomatic UTI versus ASB. An antibiotic stewardship program consisting of an educational session about antibiotic stewardship and a decision-making tool was implemented and utilized by nurses and providers. Recommendations regarding antibiotic prescribing practices for suspected UTIs and a toolkit for suspected UTIs developed by the Agency for Healthcare Research and Quality served as core elements of the antibiotic stewardship program. The rate of antibiotics prescribed for UTIs and ASB was evaluated and compared to baseline data at two months. Project Results: Baseline data revealed that 64% of antibiotic prescriptions written for suspected UTIs were aimed at ASB. Exposure to the antibiotic stewardship program decreased the rate of antibiotic prescriptions written for ASB by 18%, as the rate of antibiotics written for ASB in the post intervention period was 46%. Conclusion: The antibiotic stewardship program and decision-making tool decreased the rate of antibiotics prescribed for ASB in older adults in the long-term care setting

Protein biomarkers in cystic fibrosis research: where next?

Cystic fibrosis is one of the most common life-limiting inherited disorders. Its clinical impact manifests chiefly in the lung, pancreas, gastrointestinal tract and sweat glands, with lung disease typically being most detrimental to health. The median age for survival has increased dramatically over the past decades, largely thanks to advances in understanding of the mechanisms and consequences of disease, leading to the development of better therapies and treatment regimes. The discovery of dysregulated protein biomarkers linked to cystic fibrosis has contributed considerably to this end. This article outlines clinical trials targeting known protein biomarkers, and the current and future contributions of proteomic techniques to cystic fibrosis research. The treatments described range from those designed to provide functional copies of the mutant protein responsible for cystic fibrosis, to others addressing the associated symptoms of chronic inflammation. Preclinical research has employed proteomics to help elucidate pathways and processes implicated in disease that might present opportunities for therapy or prognosis. Global analyses of cystic fibrosis have detected the differential expression of proteins involved in inflammation, proteolytic activity and oxidative stress, which are recognized symptoms of the cystic fibrosis phenotype. The dysregulation of other processes, such as the complement and mitochondrial systems, has also been implicated. A number of studies have focused specifically on proteins that interact with the cystic fibrosis protein, with the goal of restoring its normal proteostasis. Consequently, proteins involved in synthesis, folding, degradation, translocation and localization of the protein have been identified as potential therapeutic targets. Cystic fibrosis patients are prone to lung infections that are thought to contribute to chronic inflammation, and thus proteomic studies have also searched for microbiological biomarkers to use in early infection diagnosis or as indicators of virulence. The review concludes by proposing a future role for proteomics in the high-throughput validation of protein biomarkers under consideration as outcome measures for use in clinical trials and routine disease monitoring

Synthesis of qualitative research studies regarding the factors surrounding UK critical care trial infrastructure

© 2019 Author(s). Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJConducting clinical trials in critical care is integral to improving patient care. Unique practical and ethical considerations exist in this patient population that make patient recruitment challenging, including narrow recruitment timeframes and obtaining patient consent often in time-critical situations. Units currently vary significantly in their ability to recruit according to infrastructure and level of research activity. Aim : To identify variability in the research infrastructure of UK intensive care units (ICUs) and their ability to conduct research and recruit patients into clinical trials. Design: We evaluated factors related to intensive care patient enrolment into clinical trials in the UK. This consisted of a qualitative synthesis carried out with two datasets of in-depth interviews (distinct participants across the two datasets) conducted with 27 intensive care consultants (n=9), research nurses (n=17) and trial coordinators (n=1) from 27 units across the UK. Primary and secondary analysis of two datasets (one dataset had been analysed previously) was undertaken in the thematic analysis. Findings: The synthesis yielded an overarching core theme of Normalising Research, characterised by motivations for promoting research and fostering research-active cultures within resource constraints, with six themes under this to explain the factors influencing critical care research capacity: Organisational, Human, Study, Practical resources, Clinician, and Patient/family factors. There was a strong sense of integrating research in routine clinical practice, and recommendations are outlined. Conclusions: The central and transferable tenet of Normalising Research advocates the importance of developing a culture where research is inclusive alongside clinical practice in routine patient care and is requisite for all healthcare individuals from organisational to direct patient contact level.Peer reviewedFinal Published versio

Remaking critical care:Place, body work and the materialities of care in the COVID intensive care unit

© 2023 The Authors. Sociology of Health & Illness published by John Wiley & Sons Ltd on behalf of Foundation for the Sociology of Health & Illness. This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY), https://creativecommons.org/licenses/by/4.0/In this article, we take forward sociological ways of knowing care-in-practice, in particular work in critical care. To do so, we analyse the experiences of staff working in critical care during the first wave of the COVID-19 pandemic in the UK. This moment of exception throws into sharp relief the ways in which work and place were reconfigured during conditions of pandemic surge, and shows how critical care depends at all times on the co-constitution of place, practices and relations. Our analysis draws on sociological and anthropological work on the material culture of health care and its sensory instantiations. Pursuing this through a study of the experiences of 40 staff across four intensive care units (ICUs) in 2020, we provide an empirical and theoretical elaboration of how place, body work and care are mutually co-constitutive. We argue that the ICU does not exist independently of the constant embodied work of care and place-making which iteratively constitute critical care as a total system of relations.Peer reviewe

Critical care work during COVID-19: a qualitative study of staff experiences in the UK

Objective: To understand National Health Service (NHS) staff experiences of working in critical care during the first wave of the COVID-19 pandemic in the UK. Design: Qualitative study using semistructured telephone interviews and rapid analysis, interpreted using Baehr’s sociological lens of ‘communities of fate’. Participants: Forty NHS staff working in critical care, including 21 nurses, 10 doctors and advanced critical care practitioners, 4 allied health professionals, 3 operating department practitioners and 2 ward clerks. Participants were interviewed between August and October 2020; we purposefully sought the experiences of trained and experienced critical care staff and those who were redeployed. Setting: Four hospitals in the UK. Results: COVID-19 presented staff with a situation of extreme stress, duress and social emergency, leading to a shared set of experiences which we have characterised as a community of fate. This involved not only fear and dread of working in critical care, but also a collective sense of duty and vocation. Caring for patients and families involved changes to usual ways of working, revolving around: reorganisation of space and personnel, personal protective equipment, lack of evidence for treating COVID-19, inability for families to be physically present, and the trauma of witnessing extreme patient acuity and death on a large scale. The stress and isolation of working in critical care during COVID-19 was mitigated by strong teamwork, camaraderie, pride and fulfilment. Conclusion: COVID-19 has changed working practices in critical care and profoundly affected staff physically, mentally and emotionally. Attention needs to be paid to the social and organisational conditions in which individuals work, addressing both practical resourcing and the interpersonal dynamics of critical care provision.Peer reviewe

Pseudomonas aeruginosa Cystic Fibrosis isolates of similar RAPD genotype exhibit diversity in biofilm forming ability in vitro

<p>Abstract</p> <p>Background</p> <p><it>Pseudomonas aeruginosa </it>is considered to grow in a biofilm in cystic fibrosis (CF) chronic lung infections. Bacterial cell motility is one of the main factors that have been connected with <it>P. aeruginosa </it>adherence to both biotic and abiotic surfaces. In this investigation, we employed molecular and microscopic methods to determine the presence or absence of motility in <it>P. aeruginosa </it>CF isolates, and statistically correlated this with their biofilm forming ability <it>in vitro</it>.</p> <p>Results</p> <p>Our investigations revealed a wide diversity in the production, architecture and control of biofilm formation. Of 96 isolates, 49% possessed swimming motility, 27% twitching and 52% swarming motility, while 47% were non-motile. Microtitre plate assays for biofilm formation showed a range of biofilm formation ability from biofilm deficient phenotypes to those that formed very thick biofilms. A comparison of the motility and adherence properties of individual strains demonstrated that the presence of swimming and twitching motility positively affected biofilm biomass. Crucially, however, motility was not an absolute requirement for biofilm formation, as 30 non-motile isolates actually formed thick biofilms, and three motile isolates that had both flagella and type IV pili attached only weakly. In addition, CLSM analysis showed that biofilm-forming strains of <it>P. aeruginosa </it>were in fact capable of entrapping non-biofilm forming strains, such that these 'non-biofilm forming' cells could be observed as part of the mature biofilm architecture.</p> <p>Conclusions</p> <p>Clinical isolates that do not produce biofilms in the laboratory must have the ability to survive in the patient lung. We propose that a synergy exists between isolates <it>in vivo</it>, which allows "non biofilm-forming" isolates to be incorporated into the biofilm. Therefore, there is the potential for strains that are apparently non-biofilm forming <it>in vitro </it>to participate in biofilm-mediated pathogenesis in the CF lung.</p

Exploring obstacles to critical care trials in the UK : A qualitative investigation

BACKGROUND: Clinical trials in critical care are often resource-intense, with many unique challenges. Barriers to effective recruitment and implementation of study intervention have not been explored in a UK context. AIM: To identify facilitating factors and barriers to enrolling patients into critical care clinical trials within the UK from clinician's perspectives. METHODS: A qualitative interview study was undertaken on behalf of the National Institute of Health Research critical care specialty group, in which research active clinicians across different Clinical Research Networks were interviewed. A loosely structured interview schedule was used, based on themes generated from the literature associated with accessing critical care trials. Research teams (critical care doctors, research nurses, and trial coordinators) from hospitals from each Clinical Research Network were contacted to try to achieve representation across the UK. RESULTS: Interviews were carried out across nine UK Clinical Research Networks with a range of doctors and research nurses. All hospitals were teaching hospitals with varying research nurse numbers and allocated consultant research sessions. There were a range of six to nine ongoing clinical trials in critical care for each centre representative interviewed. Data were analysed using framework analysis, and six final themes were identified related to factors associated with: centre, unit, resources, study, clinician, and patient/family. The most commonly cited barrier to conducting clinical trials was related to resources, namely insufficient human and financial resources, leading to staff and study recruitment difficulties. Clinical uncertainty and equipoise regarding comparative merits of trials were challenging in terms of engaging critical care teams. A number of patient and family factors added complexities in terms of recruitment; however, refusal rates were generally reported as low. CONCLUSION: Flexibility in funding and employment by research teams enables continuity of studies and staff. Innovative measures to incentivise research nurses and clinical teams can help recruit more patients into trials. Research teams are highly committed to providing cover to recruit critical care trials, and a significant effort to anticipate barriers is undertaken; these endeavours are summarised to provide guidance for other teams wishing to address any potential difficulties.Peer reviewe

Criteria required for an acceptable point-of-care test for UTI detection: Obtaining consensus using the Delphi technique

<div><p>Background</p><p>Urinary Tract Infections (UTIs) are common bacterial infections, second only to respiratory tract infections and particularly prevalent within primary care. Conventional detection of UTIs is culture, however, return of results can take between 24 and 72 hours. The introduction of a point of care (POC) test would allow for more timely identification of UTIs, facilitating improved, targeted treatment. This study aimed to obtain consensus on the criteria required for a POC UTI test, to meet patient need within primary care.</p><p>Methods</p><p>Criteria for consideration were compiled by the research team. These criteria were validated through a two-round Delphi process, utilising an expert panel of healthcare professionals from across Europe and United States of America. Using web-based questionnaires, panellists recorded their level of agreement with each criterion based on a 5-point Likert Scale, with space for comments. Using median response, interquartile range and comments provided, criteria were accepted/rejected/revised depending on pre-agreed cut-off scores.</p><p>Results</p><p>The first round questionnaire presented thirty-three criteria to the panel, of which 22 were accepted. Consensus was not achieved for the remaining 11 criteria. Following response review, one criterion was removed, while after revision, the remaining 10 criteria entered the second round. Of these, four were subsequently accepted, resulting in 26 criteria considered appropriate for a POC test to detect urinary infections.</p><p>Conclusion</p><p>This study generated an approved set of criteria for a POC test to detect urinary infections. Criteria acceptance and comments provided by the healthcare professionals also supports the development of a multiplex point of care UTI test.</p></div