Enhancing antimicrobial surveillance in hospitals in England: a RAND-modified Delphi

Background: Optimizing antimicrobial use (AMU) is key to reducing antimicrobial-resistant infections, but current AMU monitoring in hospital provides limited insights for quality improvement. Objectives: To understand stakeholders’ priorities for developing national AMU surveillance in English hospitals to serve the needs of national policy makers and front-line practitioners. Methods: Characteristics of existing AMU surveillance systems were identified from a previous systematic review and categorized by the Acceptability, Practicability, Effectiveness, Affordability, Side-effects and Equity (APEASE) criteria. Stakeholders prioritized characteristics using a two-round RAND-modified Delphi (rating round 1, telephone panel discussion, rating round 2). Findings informed the design of a framework used to assess the extent to which existing surveillance approaches meet stakeholders’ needs. Results: Between 17/09/19 and 01/11/19, 24 stakeholders with national and local roles related to AMU prioritized 23 characteristics of AMU surveillance describing: resource for surveillance, data collection, data availability and pathways to translate information from surveillance into practice. No existing surveillance approaches demonstrated all prioritized characteristics. The most common limitation was failure to facilitate clinician engagement with AMU through delays in data access and/or limited availability of disaggregated metrics of prescribing. Conclusions: Current surveillance delivers national public health priorities but improving stewardship demands patient-level data linked to clinical outcomes. This study offers a framework to develop current surveillance to meet the needs of local stakeholders in England. Increased investment in data infrastructure and training is essential to make information held within electronic systems available to front-line clinicians to facilitate quality improvement

A cross-sectional study of blood cultures and antibiotic use in patients admitted from the Emergency Department: missed opportunities for antimicrobial stewardship

BACKGROUND: Early review of antimicrobial prescribing decisions within 48 h is recommended to reduce the overall use of unnecessary antibiotics, and in particular the use of broad-spectrum antibiotics. When parenteral antibiotics are used, blood culture results provide valuable information to help decide whether to continue, alter or stop antibiotics at 48 h. The objective of this study was to investigate the frequency of parenteral antibiotic use, broad spectrum antibiotic use and use of blood cultures when parenteral antibiotics are initiated in patients admitted via the Emergency Department. METHODS: We used electronic health records from patients admitted from the Emergency Department at University Hospital Birmingham in 2014. RESULTS: Six percent (4562/72939) of patients attending the Emergency department and one-fifth (4357/19034) of those patients admitted to hospital were prescribed a parenteral antimicrobial. More than half of parenteral antibiotics used were either co-amoxiclav or piperacillin-tazobactam. Blood cultures were obtained in less than one-third of patients who were treated with a parenteral antibiotic. CONCLUSIONS: Parenteral antibiotics are frequently used in those admitted from the Emergency Department; they are usually broad spectrum and are usually initiated without first obtaining cultures. Blood cultures may have limited value to support prescribing review as part of antimicrobial stewardship initiatives

COVID-19 prevalence and mortality in longer-term care facilities

This essay considers the factors that have contributed to very high COVID-19 mortality in longer-term care facilities (LTCFs). We compare the demographic characteristics of LTCF residents with those of community-dwelling older adults, and then we review the evidence regarding prevalence and infection fatality rates (IFRs), including links to frailty and some comorbidities. Finally, we discuss policy measures that could foster the physical and mental health and well-being of LTCF residents in the present context and in potential future pandemics

Women\u27s Age of First Exposure to Internet Pornography Predicts Sexual Victimization

Increases in the availability and accessibility of Internet pornography have led growing numbers of children to become consumers of sexually explicit media. Research has identified negative behavioral and attitudinal outcomes associated with Internet pornography use in childhood and adolescence, but few studies have examined sexual victimization as a correlate. The current study aimed to examine the association between age of first Internet pornography exposure and sexual victimization. Data from 154 undergraduate women yielded several important findings. Women who viewed Internet pornography unintentionally at a younger age reported more sexual victimization. Specifically, compared to women who were first unintentionally exposed to Internet pornography at age 14 or older, women with unintentional first Internet pornography exposure before the age of 14 reported more childhood sexual abuse, sexual abuse in adulthood, and more instances of sexual coercion and aggression. Women with younger age of unintentional Internet pornography exposure also reported more interpersonal sexual objectification than women who had never viewed Internet pornography at all. Age of first intentional exposure to Internet pornography was not related to women’s self-reported experiences of objectification, although this may be because women’s intentional exposure tended to happen at older ages. Overall, the results of this study suggest that women’s unintentional Internet pornography exposure at a young age may contribute to a potentially harmful sexual socialization. Early Internet pornography exposure in childhood should be considered a potential risk factor for women’s sexual victimization

Factors influencing staff attitudes to COVID-19 vaccination in care homes in England: a qualitative study

BACKGROUND: The COVID-19 pandemic disproportionately affected people living and working in UK care homes causing high mortality rates. Vaccinating staff members and residents is considered the most effective intervention to reduce infection and its transmission rates. However, uptake of the first dose of the COVID-19 vaccine in care homes was variable. We sought to investigate factors influencing uptake of COVID-19 vaccination in care home staff to inform strategies to increase vaccination uptake and inform future preparedness. METHODS: Twenty care home staff including managerial and administrative staff, nurses, healthcare practitioners and support staff from nine care homes across England participated in semi-structured telephone interviews (March-June 2021) exploring attitudes towards the COVID-19 vaccine and factors influencing uptake. We used thematic analysis to generate themes which were subsequently deductively mapped to the Capability, Opportunity, Motivation-Behaviour (COM-B) model. The Behavioural Change Wheel (BCW) was used to identify potential intervention strategies to address identified influences. RESULTS: Enablers to vaccine uptake included the willingness to protect care home residents, staff and family/friends from infection and the belief that vaccination provided a way back to normality (reflective motivation); convenience of vaccination and access to accurate information (physical opportunity); and a supporting social environment around them favouring vaccination (social opportunity). Barriers included fears about side-effects (automatic motivation); a lack of trust due to the quick release of the vaccine (reflective motivation); and feeling pressurised to accept vaccination if mandatory (automatic motivation). CONCLUSIONS: We identified influences on COVID-19 vaccine uptake by care home staff that can inform the implementation of future vaccination programmes. Strategies likely to support uptake include information campaigns and facilitating communication between staff and managers to openly discuss concerns regarding possible vaccination side effects. Freedom of choice played an important role in the decision to be vaccinated suggesting that the decision to mandate vaccination may have unintended behavioural consequences

COVID-19 related mortality and hospital admissions in the VIVALDI study cohort: October 2020-March 2023

Background: Long-term care facilities (LTCFs) were heavily affected by COVID-19 early in the pandemic, but the impact of the virus has reduced over time with vaccination campaigns and build-up of immunity from prior infection. // Objectives: To evaluate the mortality and hospital admissions associated with SARS-CoV-2 in LTCFs in England over the course of the VIVALDI study, from October 2020 to March 2023. // Methods: We included residents aged ≥65 years of participating LTCFs who had available follow-up time within the analysis period. We calculated incidence rates (IR) of COVID-19 linked mortality and hospital admissions per calendar quarter, along with infection fatality ratios (IFR, within 28d) and infection hospitalisation ratios (IHR, within 14d) following positive SARS-CoV-2 test. // Results: A total of 26286 residents were included, with at least one positive test for SARS-CoV-2 in 8513 (32.4%). The IR of COVID-19 related mortality peaked in the first quarter (Q1) 2021 at 0.47 per 1000 person-days (1kpd) (around a third of all deaths), in comparison to 0.10 per 1kpd for Q1 2023 which had a similar IR of SARS-CoV-2 infections. There was a fall in observed IFR for SARS-CoV-2 infections from 24.9% to 6.7% between these periods, with a fall in IHR from 12.1% to 8.8%. The population had high overall IRs for mortality for each quarter evaluated, corresponding to annual mortality probability of 28.8-41.3%. // Conclusions: Standardised real-time monitoring of hospitalisation and mortality following infection in LTCFs could inform policy on the need for non-pharmaceutical interventions to prevent transmission

COVID-19 prevalence and mortality in longer-term care facilities

This essay considers the factors that have contributed to very high COVID-19 mortality in longer-term care facilities (LTCFs). We compare the demographic characteristics of LTCF residents with those of community-dwelling older adults, and then we review the evidence regarding prevalence and infection fatality rates (IFRs), including links to frailty and some comorbidities. Finally, we discuss policy measures that could foster the physical and mental health and well-being of LTCF residents in the present context and in potential future pandemics.publishedVersionPeer reviewe

Factors predicting amoxicillin prescribing in primary care among children: a cohort study

Background: Antibiotic prescribing during childhood contributes to antimicrobial resistance, which is a major public health concern. Antibiotics are most commonly prescribed to children for respiratory tract infections (RTI). / Aim: To identify factors associated with amoxicillin prescribing and RTI consultation attendance in primary care in young children. / Design and Setting: Cohort study in Bradford with data from pregnancy to age 24-months collected between 2007-2013, linked to electronic primary care and air pollution data. / Methods: We calculated amoxicillin prescribing rates/1,000 child-years, and fitted mixed-effects logistic regression models, with general practice (GP) surgery as the random effect, to establish risk factors for amoxicillin prescribing and RTI consultation during the first two years. / Results: Among 2,493 children, the amoxicillin prescribing rate was 710/1,000 child-years during the first year (95% CI: 677-744) and 780/1,000 (745-816) during the second year. Odds of amoxicillin prescribing during year one were higher for infants who were male (adjusted OR 1.4 (1.1-1.6)), socio-economically deprived (1.4 (1.0-1.9)), and with a Pakistani ethnic background (1.4 (1.1-1.9)). Odds of amoxicillin prescribing during the second year were higher for infants with a Pakistani ethnic background (1.5 (1.1-2.0)/1.6 (1.2-2.0)) and pre-/early-term infants (1.2 (1.0-1.5)). Additional risk factors included caesarean delivery, congenital anomalies, household overcrowding, birth season, and formal childcare attendance. GP surgery-level variation explained 7-9% of variation in amoxicillin prescribing. / Conclusions: Socio-economic status and ethnic background are strongly associated with amoxicillin prescribing and RTI consultations during childhood. Interventions reducing RTI spread in household and childcare settings may reduce antibiotic prescribing in primary care

Hospital admission after primary care consultation for community-onset lower urinary tract infection: a cohort study of risks and predictors using linked data

BACKGROUND: Urinary tract infections (UTIs) are a common indication for antibiotic prescriptions, reductions in which would reduce antimicrobial resistance (AMR). Risk stratification of patients allows reductions to be made safely. AIM: To identify risk factors for hospital admission following UTI, to inform targeted antibiotic stewardship. DESIGN AND SETTING: Retrospective cohort study of East London primary care patients. METHOD: Hospital admission outcomes following primary care consultation for UTI were analysed using linked data from primary care, secondary care, and microbiology, from 1 April 2012 to 31 March 2017. The outcomes analysed were urinary infection-related hospital admission (UHA) and all-cause hospital admission (AHA) within 30 days of UTI in primary care. Odds ratios between specific variables (demographic characteristics, prior antibiotic exposure, and comorbidities) and the outcomes were predicted using generalised estimating equations, and fitted to a final multivariable model including all variables with a P-value <0.1 on univariable analysis. RESULTS: Of the 169 524 episodes of UTI, UHA occurred in 1336 cases (0.8%, 95% confidence interval [CI] = 0.7 to 0.8) and AHA in 6516 cases (3.8%, 95% CI = 3.8 to 3.9). On multivariable analysis, increased odds of UHA were seen in patients aged 55-74 years (adjusted odds ratio [AOR] 1.49) and ≥75 years (AOR 3.24), relative to adults aged 16-34 years. Increased odds of UHA were also associated with chronic kidney disease (CKD; AOR 1.55), urinary catheters (AOR 2.01), prior antibiotics (AOR 1.38 for ≥3 courses), recurrent UTI (AOR 1.33), faecal incontinence (FI; AOR 1.47), and diabetes mellitus (DM; AOR 1.37). CONCLUSION: Urinary infection-related hospital admission after primary care consultation for community-onset lower UTI was rare; however, increased odds for UHA were observed for some patient groups. Efforts to reduce antibiotic prescribing for suspected UTI should focus on patients aged <55 years without risk factors for complicated UTI, recurrent UTI, DM, or FI