Views and experiences of community pharmacy team members on antimicrobial stewardship activities in Scotland: a qualitative study.

Background It has been acknowledged and recognised internationally that the community pharmacy team has a major role to play in antimicrobial stewardship programmes, particularly regarding patient engagement. However, there is a paucity of published research on community pharmacy-based activities in antimicrobial stewardship, and views and perceptions of the community pharmacy team on their role in antimicrobial stewardship. Objective To explore views and experiences of community pharmacy teams across Scotland on antimicrobial stewardship, activities related to European Antibiotic Awareness Day, and a self-help guide to treating infection. Setting Community pharmacy, Scotland. Methods Qualitative, semi-structured in-depth telephone interviews were undertaken with a purposive sample of community pharmacy team members over a six week period between November and December in 2016. Interviews were audio-recorded, transcribed verbatim and data analysed thematically using the framework approach. Main outcome measure Views and perceptions of antimicrobial stewardship and European Antibiotic Awareness Day activities and role of the pharmacy team. Results Twenty-seven participants were interviewed-20 pharmacists, five pharmacy graduates completing their pre-registration year, and members of the pharmacy support team including two pharmacy technicians and one medicines counter assistant. They were working mainly in urban areas and across five regions of Scotland. Most were aware of antimicrobial stewardship but some were not familiar with the term. Participants identified roles for the community pharmacy team in antimicrobial stewardship including the importance of the pharmacy as a first port of call for self-care advice. Some participants, including pharmacists, showed lack of awareness of European Antibiotic Awareness Day; those who were aware thought it may not have the desired impact on educating the public. Most participants, irrespective of role within the team, were not familiar with the self-help guide but they perceived this as a useful resource for the pharmacy team. Conclusion The participants recognised and identified roles for the community pharmacist within antimicrobial stewardship. However, the lack of awareness of European Antibiotic Awareness Day shows a need for European Antibiotic Awareness Day tools and other materials to be more effectively disseminated and for more training to be provided

Treating infections caused by carbapenemase-producing Enterobacterales (CPE): a pragmatic approach to antimicrobial stewardship on behalf of the UKCPA Pharmacy Infection Network (PIN)

open access articleThe emergence of carbapenemase-producing Enterobacterales (CPE) as a major cause of invasive infection both within the UK and internationally poses a very real concern for all providers of healthcare. The burden of morbidity and mortality associated with CPE infections is well described. The need for early, targeted, effective and safe antimicrobial therapy remains key for the management of these infected patients yet reliable antimicrobial treatment options remain scarce. In the absence of a universal treatment for these CPE invasive infections, individual treatment options tailored to susceptibilities and severity of infection are required. This working group from within the UK Clinical Pharmacy Association (UKCPA) Pharmacy Infection Network has developed evidence-based treatment recommendations to support infection specialists in managing these complex infections. A systematic review of peer-reviewed research was performed and analysed. We report consensus recommendations for the management of CPE-associated infections. The national expert panel makes therapeutic recommendations regarding the pharmacokinetic and pharmacodynamic properties of the drugs and pharmacokinetic targets, dosing, dosage adjustment and monitoring of parameters for novel and established antimicrobial therapies with CPE activity. This manuscript provides the infection specialist with pragmatic and evidence-based options for the management of CPE infections

Impact of antimicrobial stewardship interventions on <i>Clostridium difficile</i> infection and clinical outcomes:segmented regression analyses

Antimicrobial exposure is associated with increased risk of Clostridium difficile infection (CDI), but the impact of prescribing interventions on CDI and other outcomes is less clear

Limits to the biofortification of leafy brassicas with zinc

Many humans lack sufficient zinc (Zn) in their diet for their wellbeing and increasing Zn concentrations in edible produce (biofortification) can mitigate this. Recent efforts have focused on biofortifying staple crops. However, greater Zn concentrations can be achieved in leafy vegetables than in fruits, seeds, or tubers. Brassicas, such as cabbage and broccoli, are widely consumed and might provide an additional means to increase dietary Zn intake. Zinc concentrations in brassicas are limited primarily by Zn phytotoxicity. To assess the limits of Zn biofortification of brassicas, the Zn concentration in a peat:sand (v/v 75:25) medium was manipulated to examine the relationship between shoot Zn concentration and shoot dry weight (DW) and thereby determine the critical shoot Zn concentrations, defined as the shoot Zn concentration at which yield is reduced below 90%. The critical shoot Zn concentration was regarded as the commercial limit to Zn biofortification. Experiments were undertaken over six successive years. A linear relationship between Zn fertiliser application and shoot Zn concentration was observed at low application rates. Critical shoot Zn concentrations ranged from 0.074 to 1.201 mg Zn g−1 DW among cabbage genotypes studied in 2014, and between 0.117 and 1.666 mg Zn g−1 DW among broccoli genotypes studied in 2015–2017. It is concluded that if 5% of the dietary Zn intake of a population is currently delivered through brassicas, then the biofortification of brassicas from 0.057 to &gt; 0.100 mg Zn g−1 DW through the application of Zn fertilisers could increase dietary Zn intake substantially

A multicentre point prevalence survey of hospital antibiotic prescribing and quality indices in the Kurdistan Region Government of Northern Iraq : the need for urgent action

Background: Rationale antimicrobial use is crucial to address antimicrobial resistance (AMR) threats. No study has been undertaken in Iraq, using validated methodologies, to document current antimicrobial use and areas for improvement given high AMR rates. Objectives: To assess antibiotic prescribing patterns in this region using the Global PPS methodology to identify targets for quality improvement Methods: Point prevalence survey (PPS), using the Global PPS methodology, conducted among the three major public hospitals in Kurdistan Regional Government (KRG)/northern Iraq from September-December 2019. Prevalence and quality of antibiotic use were estimated/assessed using agreed quality indicators. Results: Prevalence of antibiotic use was high (93.7%;n=192/205); with third generation cephalosporins as the most commonly prescribed antibiotics (52.6%;n=140/266). Reasons for treatment was recorded for only 61.7% (n=164/266) of antibiotics and high use (89.9%) of parenteral therapy was observed. All therapy was empirical, no stop/review dates were recorded and no treatment guidelines were available. Majority of the prescribed antibiotics (62%; n=165/266) were from the WHO Watch list. Conclusions: Prevalence of antibiotic use was the highest not only in the region but globally including Africa, coupled with significant evidence of sub-optimal prescribing practice. Swift action is needed to improve future prescribing to reduce AMR. One-two areas should initially be targeted for quality improvement including development of local guidelines, documentation of antibiotic indication and/or stop/review dates

Associations Between Declining Antibiotic Use in Primary Care in Scotland and Hospitalisation with Infection and Patient Satisfaction:Longitudinal Population Study

BACKGROUND: Reducing antibiotic use is central to antimicrobial stewardship, but may have unintended consequences. OBJECTIVES: To examine associations between size of decline in antibiotic prescriptions in general practices and (i) rate of hospitalization for infection and (ii) patient satisfaction. METHODS: Routine data analysis for all general practices in Scotland, quarter one 2012 (Q1 2012) to quarter one 2018 (Q1 2018). Practices were grouped into quartiles of rate of change in prescribing and changes in rates of hospitalization were compared across groups. For satisfaction analysis, associations between practice-level patient satisfaction in 2017–18 (Scottish Health and Care Experience Survey) and prior change in antibiotic prescription were examined. RESULTS: Antibiotic prescriptions overall fell from 194.1 prescriptions/1000 patients in Q1 2012 to 165.3 in Q1 2018 (14.9% reduction). The first quartile of practices had a non-significant increase in prescriptions [change per quarter = 0.22 (95% CI −0.42 to 0.86) prescriptions/1000 patients], compared with large reductions in the other three groups, largest in quartile four: −2.95 (95% CI −3.66 to −2.24) prescriptions/1000 patients/quarter (29.7% reduction overall). In all quartiles, hospitalizations with infection increased. The increase was smallest in quartile four (the biggest reduction in prescriptions) and highest in quartile one (no significant change in prescriptions): 2.18 (95% CI 1.18 to 3.19) versus 3.68 (95% CI 2.64 to 4.73) admissions/100 000 patients/quarter, respectively [difference = − 1.50 (95% CI −2.91 to −0.10)]. There was no statistically significant association between change in antibiotic prescriptions and patient satisfaction. CONCLUSIONS: Very large reductions in antibiotic prescriptions in Scottish general practices have not been associated with increases in hospitalization with infection or changes in patient satisfaction

Validity of pneumonia severity assessment scores in low- and middle-income countries : a systematic review and meta-analysis

Background Several pneumonia severity assessment scoring systems have been developed, but the evidence of their utilisation in low- and middle-income countries (LMICs) remains limited. We sought to systematically investigate the evidence around the validity and performance of the existing pneumonia severity scores in adult patients diagnosed with community-acquired pneumonia in LMICs. Methods Medline (Ovid), Embase (Ovid), Cochrane Central Register of Controlled Trials, Scopus, and Web of Science were searched for eligible articles up to May 2020. Pooled estimates of the severity scores performance (sensitivity, specificity) at their high-risk cutoffs in predicting the reported outcome were estimated using the bivariate meta-analysis model. Heterogeneity was assessed using the I² index. Results Overall, 11 were eligible, of which, only six studies with sufficient data were included in the final meta-analysis that involved examining CURB-65 and CRB-65 scores. Both scores at a threshold ≥3 were related to an increased mortality risk, with pooled relative risks of 8.58 (95%CI: 3.48-21.18) and 4.83 (95%CI: 2.52-9.28) for CURB-65 and CRB-65, respectively. The predictive performance of CURB-65 and CRB-65 at their high-risk cutoffs, respectively, were as follows: the pooled sensitivity, 0.69 (95%CI: 0.25-0.94) and 0.04 (95%CI: 0.00-0.40); the pooled specificity, 0.89 (95%CI: 0.72-0.96) and 0.99 (95%C%: 0.95-1.00); and the area under the summary receiver operator characteristic curves, 0.90 (95%CI: 0.87-0.92) and 0.86 (95%CI: 0.83-0.89). Conclusion CURB-65 and CRB-65 at a cutoff ≥3 are strongly associated with mortality and appear to be valid scores for mortality prediction in LMICs. CURB-65 exhibited higher sensitivity and overall accuracy, compared to CRB-65

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

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

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