How do pharmacists in English general practices identify their impact? An exploratory qualitative study of measurement problems

Background: In England, there is an ongoing national pilot to expand pharmacists’ presence in general practice. Evaluation of the pilot includes numerical and survey-based Key Performance Indicators (KPIs) and requires pharmacists to electronically record their activities, possibly by using activity codes. At the time of the study (2016), no national evaluation of pharmacists’ impact in this environment had been formally announced. The aim of this qualitative study was to identify problems that English pharmacists face when measuring and recording their impact in general practice. Methods: All pharmacists, general practitioners (GPs) and practice managers working across two West London pilot sites were invited, via e-mail, to participate in a focus group study. Appropriately trained facilitators conducted two audio-recorded, semi-structured focus groups, each lasting approximately one hour, to explore experiences and perceptions associated with the KPIs. Audio-recordings were transcribed verbatim and the data analysed thematically. Results: In total, 13 pharmacists, one GP and one practice manager took part in the study. Four major themes were discerned: inappropriateness of the numerical national KPIs (“whether or not we actually have positive impact on KPIs is beyond our control”); depth and breadth of pharmacists’ activity (“we see a huge plethora of different patients and go through this holistic approach - everything is looked at”); awareness of practice based pharmacists’ roles (“I think the really important [thing] is that everyone knows what pharmacists in general practice are doing”); and central evaluation versus local initiatives (“the KPIs will be measured by National Health Service England regardless of what we think” versus “what I think is more pertinent, are there some local things we’re going to measure?”). Conclusions: Measures that will effectively capture pharmacists’ impact in general practice should be developed, along with a set of codes reflecting the whole spectrum of pharmacists’ activities. Our study also points out the significance of a transparent, robust national evaluation, including exploring the needs/expectations of practice staff and patients regarding pharmacists’ presence in general practice

Molecular epidemiology of carbapenem-resistant Pseudomonas aeruginosa in an endemic area: comparison with global data

Carbapenem-resistant Pseudomonas aeruginosa (CRPA) is an endemic problem in certain countries including Greece. CRPA and multidrug-resistant P. aeruginosa (MDRPA) firstly emerged in our region during the 80s, right after the launch of imipenem and meropenem as therapeutic agents against P. aeruginosa infections. The role of outer membrane protein (Opr) inactivation has been known to contribute to imipenem resistance since many years, while efflux overexpression systems have been mainly associated with meropenem resistance. Among carbapenemases, metallo-β-lactamases (MBL) and mostly Verona integron-mediated (VIM) MBL’s have played the most crucial role in CRPA emergence. VIM-2 and VIM-4 producing CRPA, usually belonging to clonal complexes (CC) 111 and 235 respectively, have most frequently been isolated. BlaVIM-2 and blaVIM-4 are usually associated with a class 1 integron. VIM-17 also has appeared in Greece. On the other hand, other VIM subtypes detected in a global level, such as VIM-3, VIM-5, VIM-6, VIM-7, VIM-11, VIM-14, VIM-15, VIM-16 and VIM-18 have not yet emerged in Greece. However, new VIM subtypes will probably emerge in the future. In addition, MBL carbapenemases other than VIM, detected worldwide have not yet appeared. A single CRPA isolate producing KPC has emerged in our region several years ago. The study of the molecular basis of Opr deficiency and efflux overexpression remains a challenge for the future. In this article, we review the molecular epidemiology of CRPA in an endemic area, compared to global data. © 2018, Springer-Verlag GmbH Germany, part of Springer Nature

Molecular epidemiology of carbapenem-resistant Acinetobacter baumannii in Greece: An extended review (2000-2015)

Carbapenem-resistant Acinetobacter baumannii (CRAB) is endemic in Greece. CRAB initially emerged in 2000 and since then, carbapenemases still have a crucial role in CRAB appearance, except for a few cases resulting from efflux pump or outer-membrane protein mechanisms. OXA-type carbapenemases present the highest prevalence worldwide and bla OXA-23-like and bla OXA-58-like are the most important genes found; VIM-yielding CRAB have also been detected, while a single CRAB isolate producing NDM has quite recently emerged in Greece. The predominant OXA-23 producers are associated with multilocus sequence typing Pasteur scheme sequence type 2 clonal strains of the international clone II. The emergence of colistin-resistant CRAB has complicated the treatment of such infections and the interpretation of susceptibility data. Infection control measures and adjusted antimicrobial treatment strategies could confine CRAB spread. The aim of this review is to go through the molecular epidemiology of CRAB, in an endemic area and highlight its potential future evolution. © 2017 Future Medicine Ltd

Forecasting models of infections due to carbapenem-resistant Gram-negative bacteria in an intensive care unit in an endemic area

Objectives: The aim of this study was to forecast the monthly incidence rates of infections [infections/1000 bed-days (IBD)] due to carbapenem-resistant Klebsiella pneumoniae (CRKP), carbapenem-resistant Pseudomonas aeruginosa (CRPA), carbapenem-resistant Acinetobacter baumannii (CRAB) and total carbapenem-resistant Gram-negative bacteria (CRGNB) in an endemic intensive care unit (ICU) during the subsequent year (December 2016–December 2017) following the observational period. Methods: A 52-month observational period (August 2012–November 2016) was used. Two forecasting models, including a simple seasonal model for CRGNB, CRKP and CRPA and Winters’ additive model for CRAB infections, were applied. Results: The models predicted the highest infection rates for CRKP, CRAB and CRGNB in January and September 2017 (23.8/23.4, 24.6/28.5 and 46.8/46.7 IBD, respectively) and for CRPA in February and March 2017 (8.3 and 7.9, respectively). The highest observed rates for CRKP, CRAB and CRGNB were indeed in January and September 2017 (25.6/19.0, 34.2/23.8 and 59.8/42.8 IBD, respectively); and for CRPA in February and March of the same year (15.2 and 12.7, respectively). The increased rates may be associated with personnel's annual work programme and behavioural factors. Conclusion: Forecasting models in endemic ICUs may assist in implementation strategies for infection control measures. © 2019 International Society for Antimicrobial Chemotherap

Impact of active surveillance and infection control measures on carbapenem-resistant Gram-negative bacterial colonization and infections in intensive care

Background: Carbapenem-resistant Gram-negative bacteria (CRGNB) infections constitute a global threat for critically ill patients and the outcome of their hospitalization. Early identification of CRGNB through rectal surveillance cultures and routine infection control measures including contact precautions, use of appropriate disinfectants, staff education on cleaning, and hand hygiene may reduce the dissemination of CRGNB. Aim: To assess the impact of enhanced infection control measures on CRGNB infections in a nine-bed polyvalent intensive care unit in a tertiary level hospital in an endemic area. Methods: A quasi-experimental study, which included patients with CRGNB infection retrospectively for six months and those participating in an active surveillance programme prospectively for the subsequent 22 months. Active surveillance programme (weekly rectal swabs) was implemented including two sub-periods with infection control measures and enhanced infection control measures. CRGNB incidence, prevalence, colonization pressure, infections and compliance with infection control measures and enhanced infection control measures were recorded. Analysis was performed through time-series and interrupted time-series. Findings: During the active surveillance programme, enhanced infection control measures led to a steeper downwards trend in incidence, prevalence, and colonization pressure for CRGNB compared to the infection control measures sub-period. The linear trend was for carbapenem-resistant Klebsiella pneumoniae (CRKP) and Pseudomonas aeruginosa (CRPA) infections to decrease from 19.6 to 8.1 infections per 1000 bed-days (IBD) (P = 0.001) and from 5.1 to 1.79 IBD (P = 0.043), respectively. By contrast, carbapenem-resistant Acinetobacter baumannii infections increased from 5.2 to 15.3 IBD (P = 0.001). Conclusion: Enhanced infection control measures including enhanced hand hygiene, active surveillance combined with contact precautions, education, audits and feedback policies and interventions could reduce CRKP and CRPA in endemic areas. © 2018 The Healthcare Infection Societ

Effects of an Active Surveillance Program and Enhanced Infection Control Measures on Carbapenem-Resistant Gram-Negative Bacterial Carriage and Infections in Pediatric Intensive Care

We evaluated the effects of enhanced infection control measures (ICMs) on carriage and infections of carbapenem-resistant Gram-negative bacteria (CRGNB) in a pediatric intensive care unit. We conducted a quasi-experimental study, including patients with infections of CRGNB retrospectively for 13 months and those participating in an active surveillance program prospectively for 22 months. Active surveillance (weekly rectal swabs) was implemented during a 63-week subperiod with standard ICMs and a subsequent 27-week subperiod with enhanced ICMs (intensified ICMs supplemented with audits and feedback). Prevalence, colonization pressure, incidence, and infections of CRGNB and compliance with ICMs and enhanced ICMs were recorded. Evaluation of results was performed using time series (TS) and interrupted TS. Compliance with hand hygiene improved during the second subperiod of active surveillance compared with the first; prevalence, colonization pressure, and incidence of CRGNB decreased significantly. The linear trend of centered moving average for carbapenem-resistant Klebsiella pneumoniae (CRKP) decreased from 1.2 to 0.1 infections/1,000 bed-days (IBD) (p = 0.046), while it remained unchanged for carbapenem-resistant Acinetobacter baumannii (CRAB) and increased for carbapenem-resistant Pseudomonas aeruginosa (CRPA) from 0.0 to 2.1 IBD (p < 0.001). Enhanced ICMs can reduce CRKP infections in endemic units, in contrast to CRPA and CRAB infections, which are more difficult to eradicate. © Copyright 2019, Mary Ann Liebert, Inc

Cluster-distinguishing genotypic and phenotypic diversity of carbapenem-resistant gram-negative bacteria in solid-organ transplantation patients: A comparative study

Purpose. Solid-organ transplant recipients may display high rates of colonization and/or infection by multidrug-resistant bacteria. We analysed and compared the phenotypic and genotypic diversity of carbapenem-resistant (CR) strains of Klebsiella pneumoniae, Pseudomonas aeruginosa and Acinetobacter baumannii isolated from patients in the Solid Organ Transplantation department of our hospital. Methodology. Between March 2012 and August 2013, 56 CR strains from various biological fluids underwent antimicrobial susceptibility testing with VITEK 2, molecular analysis by PCR amplification and genotypic analysis with pulsed-field gel electrophoresis (PFGE). They were clustered according to antimicrobial drug susceptibility and genotypic profiles. Diversity analyses were performed by calculating Simpson’s diversity index and applying computed rarefaction curves. Results/Key findings. Among K. pneumoniae, KP-producers predominated (57.1%). VIM and OXA-23 carbapenemases prevailed among P. aeruginosa and A. baumannii (89.4 and 88.9%, respectively). KPC-producing K. pneumoniae and OXA-23 A. baumannii were assigned in single PFGE pulsotypes. VIM-producing P. aeruginosa generated multiple pulsotypes. CR K. pneumoniae strains displayed phenotypic diversity in tigecycline, colistin (CS), amikacin (AMK), gentamicin (GEN) and cotrimoxazole (SXT) (16 clusters); P. aeruginosa displayed phenotypic diversity in cefepime (FEP), ceftazidime, aztreonam, piperacillin, piperacillin–tazobactam, AMK, GEN and CS (9 clusters); and A. baumannii displayed phenotypic diversity in AMK, GEN, SXT, FEP, tobramycin and rifampicin (8 clusters). The Simpson diversity indices for the interpretative phenotype and PFGE analysis were 0.89 and 0.6, respectively, for K. pneumoniae strains (P < 0.001); 0.77 and 0.6 for P. aeruginosa (P=0.22); and 0.86 and 0.19 for A. baumannii (P=0.004). Conclusion. The presence of different antimicrobial susceptibility profiles does not preclude the possibility that two CR K. Pneumoniae or A. baumannii isolates are clonally related. © 2017 The Authors

Successful management of an outbreak due to carbapenem-resistant Acinetobacter baumannii in a neonatal intensive care unit

The investigation and successful management of a monoclonal Acinetobacter baumannii outbreak in a neonatal intensive care unit are described. Upon the first clustered carbapenem-resistant A. baumannii (CRAB) infections, a bundle of actions were taken, including enhanced infection control, active surveillance (weekly stool samples), casecontrol study, staff education, daily audits and discontinuation of new admissions. Between September and December 2011, eight neonates developed 10 CRAB infections (five blood, four respiratory and one eye). A total of 216 active surveillance cultures were obtained from 96 neonates (43 % had ≥2 samples). During weeks 12, 16 and 17, active surveillance detected 3, 1 and 2 new CRAB acquisitions, respectively. Prevalence of infections/colonizations decreased, and no event occurred after 20th week. A colonized neonate developed CRAB sepsis and died. All CRAB isolates harboured blaOXA-58 and the intrinsic chromosomal blaOXA-51 carbapenemase genes. Conclusion: Active surveillance and enhanced infection control measures effectively contained spread of CRAB clone in the neonatal intensive care unit. © Springer-Verlag Berlin Heidelberg 2014

Polyclonal predominance of concurrently producing OXA-23 and OXA-58 carbapenem-resistant Acinetobacter baumannii strains in a pediatric intensive care unit

We report a predominance (64.7%) of polyclonal carbapenem-resistant Acinetobacter baumannii (CRAB) strains concurrently producing OXA-23 and OXA-58 carbapenemases in a pediatric intensive care unit in an endemic area. This is the first report of emergence of such double-OXA CRAB strains in a single unit worldwide. © 2019, Springer Nature B.V