Appropriateness of acute-care antibiotic prescriptions for community-acquired infections and surgical antibiotic prophylaxis in England: analysis of 2016 national point prevalence survey data

BACKGROUND

Estimates of inappropriate prescribing can highlight key target areas for antimicrobial stewardship (AMS) and inform national targets.

OBJECTIVES

To (1) define and (2) produce estimates of inappropriate antibiotic prescribing levels within acute hospital trusts in England.

METHODS

The 2016 national Healthcare-Associated Infections (HAI), Antimicrobial Use (AMU) and AMS point prevalence survey (PPS) was used to derive estimates of inappropriate prescribing, focusing on the four most reported community-acquired antibiotic indications (CAIs) in the PPS and surgical prophylaxis. Definitions of appropriate antibiotic therapy for each indication were developed through the compilation of national treatment guidelines. A Likert-scale system of appropriateness coding was validated and refined through a two-stage expert review process.

RESULTS

Antimicrobial usage prevalence data were collected for 25,741 individual antibiotic prescriptions, representing 17,884 patients and 213 hospitals in England. 30.4% of prescriptions for the four CAIs of interest were estimated to be inappropriate (2054 prescriptions). The highest percentage of inappropriate prescribing occurred in uncomplicated cystitis prescriptions (62.5%), followed by bronchitis (48%). For surgical prophylaxis, 30.8% of prescriptions were inappropriate in terms of dose number, and 21.3% in terms of excess prophylaxis duration.

CONCLUSIONS

The 2016 prevalence of inappropriate antibiotic prescribing in hospitals in England was approximated to be 30.4%; this establishes a baseline prevalence and provided indication of where AMS interventions should be prioritized. Our definitions appraised antibiotic choice, treatment duration and dose number (surgical prophylaxis only); however, they did not consider other aspects of appropriateness, such as combination therapy - this is an important area for future work.

Detection, survival, and persistence of Staphylococcus capitis NRCS-A in neonatal units in England

BACKGROUND

The multidrug-resistant Staphylococcus capitis clone, NRCS-A, is increasingly associated with late-onset sepsis in low birthweight newborns in neonatal intensive care units (NICUs) in England and globally. Understanding where this bacterium survives and persists within the NICU environment is key to developing and implementing effective control measures.

AIM

To investigate the potential for S. capitis to colonize surfaces within NICUs.

METHODS

Surface swabs were collected from four NICUs with and without known NRCS-A colonizations/infections present at the time of sampling. Samples were cultured and S. capitis isolates analysed via whole-genome sequencing. Survival of NRCS-A on plastic surfaces was assessed over time and compared to that of non-NRCS-A isolates. The bactericidal activity of commonly used chemical disinfectants against S. capitis was assessed.

FINDINGS

Of 173 surfaces sampled, 40 (21.1%) harboured S. capitis with 30 isolates (75%) being NRCS-A. Whereas S. capitis was recovered from surfaces across the NICU, the NRCS-A clone was rarely recovered from outside the immediate neonatal bedspace. Incubators and other bedside equipment were contaminated with NRCS-A regardless of clinical case detection. In the absence of cleaning, S. capitis was able to survive for three days with minimal losses in viability (<0.5 log10 reduction). Sodium troclosene and a QAC-based detergent/disinfectant reduced S. capitis to below detectable levels.

CONCLUSION

S. capitis NRCS-A can be readily recovered from the NICU environment, even in units with no recent reported clinical cases of S. capitis infection, highlighting a need for appropriate national guidance on cleaning within the neonatal care environment.

Rapid diagnostic tests for common infection syndromes: less haste, more speed

Rapid diagnostic tests, which accurately distinguish bacterial from viral infections, are being heralded as the solution to antibiotic overuse, which is a key driver of antimicrobial resistance. We have concerns that this approach is oversimplistic. Rapid diagnostic tests are complex interventions, with clinical context, patient flow, access and timing affecting their impact. There is little robust evidence that they reduce antibiotic prescribing in real-world settings. We suggest that prior to introducing these costly tests, emphasis should be placed on optimizing the implementation of efficient evidence-based antimicrobial stewardship interventions, such as increasing the use of proven automated clinical infection syndrome prediction tools by clinicians, supporting patients to self-care by providing them with high-quality safety-netting resources, providing front-line clinicians with individual prescribing data to facilitate peer benchmarking and setting specific and purposeful antibiotic prescribing targets to improve the quality of antimicrobial prescribing. The stakes are high and time is running out; let's start by getting the basics right.

Paediatric antimicrobial stewardship programmes in the UK's regional children's hospitals

A survey was conducted in UK regional children's hospitals with paediatric intensive care and paediatric infectious disease (PID) departments to describe the characteristics of paediatric antimicrobial stewardship (PAS) programmes. A structured questionnaire was sent to PAS coordinators. 'Audit and feedback' was implemented in 13 out of 17 centres. Microbiology-led services were more likely to implement antimicrobial restriction (75% vs 33% in PID-led services), to focus on broad-spectrum antibiotics, and to review patients with positive blood cultures. PID-led services were more likely to identify patients from e-prescribing or drug charts and review all antimicrobials. A PAS network has been established.

Dental maturity in Belgian children using Demirjian's method and polynomial functions: new standard curves for forensic and clinical use

Dental maturity was studied from dental panoramic radiographs of 2523 Belgian children (1255 girls and 1268 boys) aged 2 to 18 years. The aim was to compare the efficiency of two methods of age prediction: Demirjian's method, using differently weighted scores, and polynomial functions. The two methods present some differences: Demirjian is used to determine the maturity score as a function of age and polynomial functions are used to determine age as a function of the maturity score. We present, for each method, gender-specific dental maturity tables and curves for Belgian children. Girls always present advanced dental maturity compared with boys. The polynomial functions are highly reliable (0.21% of incorrect classifications) and the percentile method, using Belgian weighted scores, is very accurate (+/- 2.08 years on average, between 2 and 16 years of age).

A single H:CDR3 residue in the anti-digoxin antibody 26-10 modulates specificity for C16-substituted digoxin analogs

We constructed Fab libraries of bacteriophage-displayed H:CDR3 mutants in the high-affinity anti-digoxin antibody 26-10 to determine structural constraints on affinity and specificity for digoxin. Libraries of mutant Fabs randomized at five or 10 contiguous positions were panned against digoxin and three C16-substituted analogs, gitoxin (16-OH), 16-formylgitoxin and 16-acetylgitoxin. The sequence data from 83 different mutant Fabs showed highly restricted consensus patterns at positions H:100, 100a and 100b for binding to digoxin; these residues contact digoxin in the 26-10:digoxin co-crystal structure. Several mutant Fabs obtained following panning on digoxin-BSA showed increased affinity for digoxin compared with 26-10 and retained the wild-type (wt) Trp at position 100. Those Fabs selected following panning on C16-substituted analogs showed enhanced binding to the analogs. Replacement of H:Trp100 by Arg resulted in mutants that bound better to the analogs than to digoxin. This specificity change was unexpected, as C16 lies on the opposite side of digoxin from H:CDR3. Substitution of wt Trp by Arg appears to alter specificity by allowing the hapten to shift toward H:CDR3, thereby providing room for C16 substituents in the region of H:CDR1.

Longitudinal post-eruptive mandibular tooth movements of males and females

Unbiased estimates of post-eruptive eruption and migration of the mandibular teeth for large representative samples are presently unavailable. The purpose of this study was to evaluate pure tooth movements of untreated children and adolescents longitudinally. Lateral cephalograms of 214 French-Canadians, followed bi-annually between 8 and 15 years of age, were traced, and the positions of the mandibular permanent central incisors and first molars were digitized. Temporal changes in tooth position were evaluated relative to naturally stable mandibular reference structures, using the mandibular reference line for orientation. The statistical analyses included t-tests to assess gender differences and Pearson product-moment correlations to evaluate associations. The results showed that the incisors proclined significantly more for males (6 degrees) than females (3 degrees). The incisor tips displayed early mesial movements that were countered by later distal movements. The incisor apex showed a consistent pattern of distal migration between 8 and 15 years. Mandibular arch length decreased over the 7-year observation period. Rates of mesial molar migration accelerated until 11 years of age and then decelerated. There was no significant change in the mandibular occlusal plane angle between 8 and 15 years of age. Incisor eruption showed the greatest rates during adolescence, attaining peaks at approximately 12 years for females and 14 years for males. The molars erupted approximately 5 mm between 8 and 15 years of age. The greatest gender differences occurred at the older ages, with males showing greater eruption potential than females. It was concluded that the mandibular teeth show significant migration and eruption during childhood and adolescence, with gender differences in the amount, direction, and timing of movement.

Incremental growth charts for condylar growth between 6 and 16 years of age

This study provides sex specific reference data for the incremental growth of the mandibular condyle. The results pertain to a mixed-longitudinal sample of 113 males and 108 females followed annually between 6 and 16 years of age (total of 1647 observations). Growth of condylion was evaluated using naturally stable mandibular reference structures. The mean growth curves were estimated by multilevel models using iterative least squares procedures; between subject variation was estimated based on the sample's percentile distributions. Mean yearly velocities of condylar growth for males ranged between 2.1 and 3.1 mm/year. Growth rates decreased during childhood, increased during adolescence, and attained a maximum of 3.1 mm/year at approximately 14.3 years of age. Females showed a more constant rate of condylar growth during childhood (2.0-2.7 mm/year), a smaller adolescent peak (2.3 mm/year) at approximately 12.2 years and rapid deceleration after the peak. These reference data offer orthodontists an objective means of evaluating growth potential and treatment outcome in individual patients. Charts are provided for evaluating condylar growth of individual patients.

Multimedia approach to dental education in the 21st century

Today's technology allows educators to design and create tools that enable teachers and students to work with material from different sources and to attend courses at various sites. The personal computer represents perhaps the greatest boon to this movement by providing a vehicle for "user friendly," interactive, multimedia courseware. A discussion of that courseware, its development and implementation, is provided here.

Longitudinal shape changes of the nasal dorsum

This investigation quantifies childhood and adolescent growth changes of the upper and lower nasal dorsum and evaluates various aspects of the persons' morphology that relate to shape changes of the dorsum. A longitudinal sample of 37 French-Canadian girls, each having cephalograms at 6, 10, and 14 years of age, was evaluated. The 6- to 10-year interval was chosen to represent childhood growth; the 10- to 14-year interval represented adolescent growth. The upper dorsum rotates upward and forward (counterclockwise) approximately 10 degrees between 6 to 14 years of age. The lower dorsum shows both downward and backward (clockwise) and upward and forward (counterclockwise) rotation average childhood and adolescent changes in angulation were not significant. The results clearly indicate that changes in the nasal dorsum are most closely related to angulation changes of the lower dorsum, particularly during adolescence. The lower dorsum rotates downward and backward in persons who show greater vertical and less horizontal growth changes. Rotational changes of the lower dorsum are most closely related with vertical changes at pronasale.

Mandibular rotation and angular remodeling during childhood and adolescence

Using the structural method of superimposition, childhood and adolescent rates of mandibular rotation and remodeling are described. The results pertain to a longitudinal sample of French-Canadian children, including 42 females with records at 6, 10, and 14 years of age and 39 males with records at 7, 11, and 15 years of age. There are no sex differences in rates of mandibular rotation and remodeling. Childhood rates of true rotation and angular remodeling are significantly greater than adolescent rates. Children whose first permanent molars had not erupted at the time of the first observation showed significantly greater rates of angular remodeling than children whose molars had already erupted. Over the eight year period, there were approximately 4.8 degrees of forward true rotation, between 5.2 and 6.4 degrees forward angular remodeling, and less than 1 degree of backward apparent rotation. During adolescence and the primary dentition stage, associations are strongest between true and apparent rotation. During the mixed dentition stage, true rotation is most closely correlated with angular remodeling. © 1992 Wiley-Liss, Inc.

A new teaching tool for dental and medical schools: multimedia CD-ROM on dental and skeletal development

Multimedia teaching tools in Medicine are still very rare. Their presentation on a CD-ROM format is part of the emerging technologies in Medical Informatics. The Multimedia material presented here on Dental and Skeletal Development is mostly a Database and a Tutorial. The Database, which contains more than 2000 hand/wrist radiographs, is mostly intended for Pediatricians, Endocrinologists, Forensic Dentists and Physicians, as well as for Orthodontists and Pedodontists. The material is the result of 20-year of Longitudinal Growth study of children in Montreal. In this Multimedia CD-ROM, the research results are used for Medical teaching purposes.

Mandibular growth prediction: mean growth increments versus mathematical models

The aim of this study was to compare growth predictions obtained by adding mean annual velocities with predictions derived from a polynomial model of the population's growth curve. Given the child's previous measures at 11, 12 and/or 13 years of age, the cephalometric distance sella-gnathion at 15 years was estimated. Based on a sample of 223 boys and girls, the root mean square error decreased from 0.28 cm (males) and 0.18 cm (females) at 11 years, to 0.19 cm (males) and 0.12 cm (females) at 13 years. Root mean square errors were similar between methods, which was due to high correlations between measures across ages. Significantly, predictions based on mean increments were biased. They often over or underestimate growth for children who are larger and smaller than average. The observed bias was due to expected changes of variance associated with growth, which unconditional methods of prediction cannot control for. Predictions derived from growth models are conditional upon the child's size and are, therefore, unbiased.

Modeling longitudinal mandibular growth: percentiles for gnathion from 6 to 15 years of age in girls

Growth of the cephalometric landmark gnathion is modeled mathematically with multilevel statistical techniques. The findings, pertaining to a mixed longitudinal sample (N = 772) of 105 girls, 6 to 15 years of age, provide the most accurate descriptions of longitudinal mandibular growth presently available. Polar, rather than rectangular, coordinates are used to better distinguish between the amount and direction of growth. The velocity curve for sella-gnathion includes growth spurts during childhood (7.5 years) and adolescence (12.7 years). Growth direction of gnathion changes regularly throughout the age range, indicating a relative increase of vertical over horizontal growth. These reference standards serve as a basis for comparing and better understanding abnormal growth patterns.

Pubertal growth of the cephalometric point gnathion: multilevel models for boys and girls

Two-level polynomial models are used to summarize the amount Sella-Gnathion (S-Gn) and direction Nasion-Sella-Gnathion (N-S-Gn) of growth changes for the cephalometric landmark gnathion. Growth descriptions pertain to a mixed longitudinal sample of 209 French-Canadian children 10-15 years of age. The boy's growth curve attains mean minimum prepubertal velocity at 10.8 years and maximum pubertal velocity at 14.1 years. The girl's curve follows a cubic pattern, attaining maximum pubertal velocity at 12.1 years. Boys are larger than girls throughout the age range. Variation between-subjects increases with age in a curvilinear fashion. Growth direction of gnathion is more horizontally directed for girls than boys. Small but significant changes in growth direction occur between 10 and 15 years of age.

Cephalometric reliability. A full ANOVA model for the estimation of true and error variance

A detailed description of sampling designs for assessing the reliability of cephalometric measurements, emphasizing distinctions between true and observed variance, random and systemic components of variance, and complete and minimal models for evaluating measurement error.

A polynomial approach to craniofacial growth: description and comparison of adolescent males with normal occlusion and those with untreated Class II malocclusion

Orthogonal polynomials are used to model the craniofacial growth of adolescent boys, aged 11 through 14 years, and to evaluate variation between normal occlusion and untreated Class II malocclusion. The results show linear growth (velocity) for the maxillary measures; their angular relationships to the cranial base remain stable throughout the age range. Mandibular measures show growth velocity and acceleration, indicating the adolescent growth spurt. For the majority (80%) of measures, boys with normal occlusion and those with Class II malocclusion were not significantly different. Mean growth velocity of basion-nasion is significantly greater for subjects with Class II, Division 1 malocclusion. Total mandibular length and the ANB angle display significant mean size (constant) differences between boys with normal occlusion and boys with untreated Class II malocclusion. The groups are comparable in growth velocity and acceleration, indicating that the size differences are established before 11 years of age and maintained during adolescence.

Sexual dimorphism in mandibular growth of French-Canadian children 6 to 10 years of age

Polynomial regression is used to model the mandibular growth of 28 girls and 26 boys who were followed longitudinally from 6 to 10 years of age. The pooled-within individual designs indicate that ramus height follows a linear pattern of size increase; corpus and total mandibular lengths display curvilineal, decelerating, patterns of growth over the age range. Multivariate analyses of variance reveal significant sex differences in size, favoring boys, for the two length measures at 6 years of age. Growth velocity for corpus length is also significantly greater in boys than in girls. Sexual dimorphism in the growth of total mandibular length is more complex, including differences in velocity and deceleration. Ramus height shows no significant pattern of variation between boys and girls for either size or growth velocity.

Sexual dimorphism in the emergence of deciduous teeth: its relationship with growth components in height

Sexual dimorphism in the emergence of the deciduous dentition of French-Canadian children may be explained by differences in recumbent length. Relative to the chronological age scale, boys are longer and their teeth emerge earlier than girls. Recumbent lengths attained at the exact age of emergence, as estimated by fifth-order polynomials fitted to each subject's serial data, are comparable between the sexes. Multi- and univariate analyses of variance show no significant sex differences in the lengths attained at the age of emergence of the deciduous teeth. These findings suggest that clinical standards for emergence of deciduous teeth scaled relative to length rather than chronological age are more accurate and efficient.

Interrelationships among measures of somatic, skeletal, dental, and sexual maturity

The interrelationships among five measures of physiologic maturity for 50 French-Canadian girls are evaluated--menarche, peak height velocity (PHV), 75% skeletal maturity, appearance of the ulnar sesamoid, and 90% dental development. The mean ages of occurrence of the events differed significantly (P less than 0.01). Menarche and 90% dental maturity showed the least variability. Ages of PHV, menarche, and 75% skeletal maturity were significantly correlated (P less than 0.05). Age of menarche was most closely associated with PHV. The appearance of the ulnar sesamoid was highly correlated with 75% skeletal maturity; both were equally related to the ages of PHV and menarche. The age at which French-Canadian girls attain 90% of their dental development showed no significant relationships with the other maturity indicators. The results imply that the mechanisms controlling dental development are independent of somatic and/or sexual maturity.

Adjusting craniofacial correlations for technical error

Reliability estimates provide a means of adjusting observed correlations for technical error. The results show that the true correlations among 11 craniofacial landmarks are consistently higher than observed values. Consequently, the regression slopes defining these relationships are also increased. The less reliable two measures are, and the closer their joint reliability approximates the observed correlation, the greater the expected change in true correlation. Adjusting craniofacial relationships for technical error may substantially increase the proportion of variation explained, and thereby alter statistical inferences drawn from results.

Effects of premature loss of deciduous molars

A statistical exploration of space changes following early loss of deciduous molars, developing a picture of closure from both directions with district differences between upper and lower arch changes.

Sexual dimorphism in the emergence of the deciduous teeth

Exact ages of emergence of the twenty deciduous teeth have been investigated on a longitudinal sample of 195 French-Canadian children (113 boys and 82 girls). A multivariate analysis of variance yielded a significant overall sex difference (p less than 0.0001). It has been found that the emergence of the deciduous dentition in boys is more precocious than that in girls by about one month; this difference is present at the emergence of the upper central incisor and is maintained henceforth. The only notable exception to this pattern is the emergence of the first molars. Results of the present study, combined with those of previous research, suggest that sexual dimorphism in the emergence of the deciduous teeth could be mediated through ethnic factors.

The inter-examiner variation in rating dental formation from radiographs

Six examiners evaluated dental formation on 191 radiographs, using an eight-stage system. Discrepancies between these examiners are generally of the order of +/- one stage, in about 20 to 25% of the cases. The authors thus suggest the use of reference radiographs, for the double purpose of ensuring a homogeneous rating by two examiners or more, as well as the assessment of eventual differences between populations.

Sexual differences in dental development and prediction of emergence

The dental development of a genetically homogeneous French-Canadian group of children ranging in age from 2.5 to 19 years was evaluated from 5,437 panoramic radiographs by the method of Demirjian et al. The maturity of each mandibular tooth was evaluated individually. For each stage of each tooth, the developmental curves of boys and girls were compared. A common pattern was found for each tooth, namely the chronological similarity between boys and girls in the early stages of development and the advancement of girls over boys for the later stages. Development scores were given to the seven mandibular teeth. Up to five to six years of age, no difference was found in the timing of dental development between boys and girls, in contrast to the older ages where girls were always more developed than boys. When the emergence curve was plotted with developmental curves, a close relation was established between the stage of formation of all teeth and their emergence, hence the predictive value of the use of dental maturity curves in clinics.

Heritability estimates of somatotype components based upon familial data

Somatotype components were obtained in 239 French-Canadian families from Montreal. Endomorphy, mesomorphy and ectomorphy were anthropometrically assessed in the Health and Carter system. All three components were available in 208 pairs of siblings, while only ectomorphy was estimated in 507 parent-child pairs. Sibling correlations reached 0.40 for endomorphy, 0.30 for mesomorphy, and 0.38 for ectomorphy. Partialling out the effects of 7 socioeconomic indicators permitted an estimate of common familial environment upon covariation between relatives. Residual sibling correlations yielded broad heritability estimates (HB) of 0.50 for endomorphy, 0.42 for mesomorphy and 0.54 for ectomorphy. Narrow heritability (HN) for ectomorphy, controlling for familial indicators, was approximately 0.36 including a positive contribution from assortative mating.

Sexual dimorphism in body composition changes during the pubertal period: as shown by French-Canadian children

Size and velocity growth curves of stature to represent skeletal growth, lean arm circumference to represent muscle growth, and the sum of three skinfolds to represent fat tissue changes, are presented for a longitudinal study of Montreal school-age chidren. Both a chronological age scale, and one relative to the individual ages of peak growth velocity in stature, are used. Intercorrelations between the various components are tabulated for age groups based on the two scales. The three skinfolds are also analyzed separately. The results show that such simple anthropometric measures can be usefully taken to represent the growth of different body components. Longitudinal analysis reveals that, whereas the relationship of muscular to statural growth in boys is purely maturational, it is not so for girls, and that the different skinfolds show complex sexual differences in growth during the pubertal period.

The pattern of facial growth before and during puberty, as shown by French-Canadian girls

The results are reported for an analysis of longitudinal sequences of lateral head X-rays of 50 Montreal girls, taken annually between the ages of 6 and 15 years. Mean size changes for distances within the cranial base, the maxilla and the mandible, as well as those outlining the facial polygon, are displayed on a common proportional scale based on mean sizes at 15 years old. Mean growth velocities are displayed on both a chronological age scale and on one relative to the individual age of peak growth velocity in stature. A distinct facial pattern of growth is established, In terms of the proportion of final size achieved during childhood, it is below the cranial pattern, but above the general skeletal one. This facial pattern shows a pubertal peak in growth, but one quantitatively less important than that for stature. The timing of the two peaks is closely aligned, although the evidence favours a slightly later development for the face. The mandibular ramus provided the sole exception to this common facial pattern, though some questions on maxillary growth remain open.