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

Mechanisms affecting the implementation of a national antimicrobial stewardship programme; multi-professional perspectives explained using normalisation process theory.

Background: Antimicrobial stewardship (AMS) describes activities concerned with safe-guarding antibiotics for the future, reducing drivers for the major global public health threat of antimicrobial resistance (AMR), whereby antibiotics are less effective in preventing and treating infections. Appropriate antibiotic prescribing is central to AMS. Whilst previous studies have explored the effectiveness of specific AMS interventions, largely from uni-professional perspectives, our literature search could not find any existing evidence evaluating the processes of implementing an integrated national AMS programme from multi-professional perspectives. Methods: This study sought to explain mechanisms affecting the implementation of a national antimicrobial stewardship programme, from multi-professional perspectives. Data collection involved in-depth qualitative telephone interviews with 27 implementation lead clinicians from 14/15 Scottish Health Boards and 15 focus groups with doctors, nurses and clinical pharmacists (n = 72) from five Health Boards, purposively selected for reported prescribing variation. Data was first thematically analysed, barriers and enablers were then categorised, and Normalisation Process Theory (NPT) was used as an interpretive lens to explain mechanisms affecting the implementation process. Analysis addressed the NPT questions 'which group of actors have which problems, in which domains, and what sort of problems impact on the normalisation of AMS into everyday hospital practice'. Results: Results indicated that major barriers relate to organisational context and resource availability. AMS had coherence for implementation leads and prescribing doctors; less so for consultants and nurses who may not access training. Conflicting priorities made obtaining buy-in from some consultants difficult; limited role perceptions meant few nurses or clinical pharmacists engaged with AMS. Collective individual and team action to implement AMS could be constrained by lack of medical continuity and hierarchical relationships. Reflexive monitoring based on audit results was limited by the capacity of AMS Leads to provide direct feedback to practitioners. Conclusions: This study provides original evidence of barriers and enablers to the implementation of a national AMS programme, from multi-professional, multi-organisational perspectives. The use of a robust theoretical framework (NPT) added methodological rigour to the findings. Our results are of international significance to healthcare policy makers and practitioners seeking to strengthen the sustainable implementation of hospital AMS programmes in comparable contexts

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

Optimising carbapenem use through a national quality improvement programme

Background: Concern about increasing carbapenem and piperacillin/tazobactam use led the Scottish Antimicrobial Prescribing Group (SAPG) to develop national guidance on optimal use of these agents, and to implement a quality improvement programme to assess the impact of guidance on practice. Objectives: To evaluate how SAPG guidance had been implemented by health boards, assess how this translated into clinical practice, and investigate clinicians’ views and behaviours about prescribing carbapenems and alternative agents. Methods: Local implementation of SAPG guidance was assessed using an online survey. A bespoke Point Prevalence Survey was used to evaluate prescribing. Clinicians’ experience of using carbapenems and alternatives was examined through semi-structured interviews. National prescribing data were analysed to assess the impact of the programme. Results: There were greater local restrictions for carbapenems than for piperacillin/tazobactam. Laboratory result suppression was inconsistent between boards and carbapenem sparing antibiotics were not widely available. Compliance with local guidelines was good for meropenem but lower for piperacillin/tazobactam. Indication for use was well documented but review/stop dates were poorly documented for both antibiotics. Decisions to prescribe a carbapenem were influenced by local guidelines and specialist advice. Many clinicians lacked confidence to de-escalate treatment. Use of both antibiotics decreased during the course of the programme. Conclusions: A multi-faceted quality improvement programme was used to gather intelligence, promote behaviour change and focus interventions on use of carbapenems and piperacillin/tazobactam. Use of these antimicrobials decreased during the programme; a trend not seen in Europe outwith the UK. The programme could be generalised to other antimicrobials

Far Ultraviolet Imagery of the Edge-On Spiral Galaxy NGC 4631

Far ultraviolet FUV imagery of the edge-on, Sc/SBd galaxy, NGC 4631 reveals very strong FUV emission, resulting from active star formation, uniformly distributed along the galactic mid- plane. Multi-band imagery, HI and HII position-velocity curves and extinction considerations all imply that the emission is from the outer edges of the visible galaxy. The overall FUV morphology of this edge-on disk system is remarkably similar to those of the so-called "chain galaxies" evident at high redshift, thus suggesting a similar interpretation for at least some of those distant objects. FUV, U, B and V magnitudes, measured for 48 star forming regions, along with corresponding H-alpha and H-beta measurements are used to construct diagnostic color-color diagrams. Although there are significant exceptions, most of the star forming regions are less massive and older than 30 Doradus. Comparison with the expectations from two star formation models yields ages of 2.7 to 10 Myr for the instantaneous burst (IB) model and star formation cut-off ages of 0 to 9 Myr for the continuous star formation (CSF) model. Interpreted in terms of the IB model the photometry implies a total created mass in the 48 star forming regions of 25 million solar-masses. When viewed as resulting from constant star formation the photometry implies a star formation rate of 0.33 solar-masses/yr. These results are compared to those derived from FIR and radio observations. Corrections for FUV emission reprocessed by interstellar grains are estimated.Comment: 29 pages including 6 encapsulated Postscript figures; accepted for publication in ApJ; changed table forma

The James Webb Space Telescope Mission

Twenty-six years ago a small committee report, building on earlier studies, expounded a compelling and poetic vision for the future of astronomy, calling for an infrared-optimized space telescope with an aperture of at least $4m$. With the support of their governments in the US, Europe, and Canada, 20,000 people realized that vision as the $6.5m$ James Webb Space Telescope. A generation of astronomers will celebrate their accomplishments for the life of the mission, potentially as long as 20 years, and beyond. This report and the scientific discoveries that follow are extended thank-you notes to the 20,000 team members. The telescope is working perfectly, with much better image quality than expected. In this and accompanying papers, we give a brief history, describe the observatory, outline its objectives and current observing program, and discuss the inventions and people who made it possible. We cite detailed reports on the design and the measured performance on orbit.Comment: Accepted by PASP for the special issue on The James Webb Space Telescope Overview, 29 pages, 4 figure

Co-infections and antimicrobial use among hospitalized COVID-19 patients in Punjab, Pakistan : findings from a multicenter, point prevalence survey

There are reports of high rates of antibiotic prescribing among hospitalized patients with COVID-19 around the world. To date, however, there are few reports of prescribing in relation to COVID-19 in Pakistan. Herein, we describe a point prevalence survey of antibiotic prescribing amongst patients hospitalized with suspected or proven COVID-19 in Pakistan. A Point Prevalence Survey (PPS) was undertaken in seven tertiary care health facilities in Punjab Provence, Pakistan. Baseline information about antimicrobial use according to the World Health Organization (WHO) standardized methodology was collected on a single day between 5 and 30 April 2021. A total of 617 patients' records were reviewed and 578 (97.3%) were documented to be receiving an antibiotic on the day of the survey. The majority (84.9%) were COVID-19 PCR positive, 61.1% were male and 34.9% were age 36 to 44 years. One quarter presented with severe disease, and cardiovascular disease was the major comorbidity in 13%. Secondary bacterial infection or co-infection (bacterial infection concurrent with COVID-19) was identified in only 1.4%. On the day of the survey, a mean of 1.7 antibiotics was prescribed per patient and 85.4% antibiotics were recorded as being prescribed for 'prophylaxis'. The most frequently prescribed antibiotics were azithromycin (35.6%), ceftriaxone (32.9%) and meropenem (7.6%). The majority (96.3%) of the antibiotics were empirical and all were from WHO Watch or Reserve categories. Overall, a very high consumption of antibiotics in patients hospitalized with suspected or proven COVID-19 was observed in Pakistan and this is concerning in view of already high rates of antimicrobial resistance in the region. Antimicrobial stewardship programs need to urgently address unnecessary prescribing in the context of COVID-19 infection