Exploring the appearance of and messaging on antibiotics to address inappropriate antibiotic use - public and pharmacists views

Introduction

The purpose of medicines labelling and packaging is to provide clear unambiguous identification of the medicine and the conditions for its safe use, allowing patients to understand and act on the information.1 Inappropriate antibiotic usage, (deviation from directions provided to the patients by the prescriber, resulting in sub-optimal treatment) may result in exposing bacteria to sub-therapeutic plasma concentrations and/or environment, which are one of the main drivers of Antibiotic Resistance.2 A recent comprehensive analysis showed the global burden associated with drug-resistant infections in 2019 was an estimated 4.95 million deaths.3

Aim

To ascertain the support from pharmacists and the public and their perceptions on the likely barriers to harmonising or standardising physical appearance and/or messaging on antibiotic packaging to reduce inappropriate antibiotic usage.

Methods

This study received ethics approval from the University of Huddersfield. In partnership with NHS England Antimicrobial Stewardship lead for North-East and Yorkshire, two questionnaires (public and pharmacist) were piloted. The final version was transferred to Qualtrics (online questionnaire format). During a 5-week period public questionnaires were distributed via posters with QR codes and social media. Pharmacist questionnaires were emailed to consenting pharmacists (community, hospital, GP practice, industry) around Huddersfield, Doncaster, Rochdale, Dewsbury and Leeds. The data underwent descriptive statistical analysis.

Results

Inappropriate antibiotic usage (saving for future use) was admitted by 23.5% of the 174 public participants, sharing with others (2.5%), throwing their antibiotics in the bin (32.7%) and other inappropriate usage was reported. This compared to 22.2% returning antibiotics to the pharmacy for disposal. 100% of pharmacists (40) think inappropriate antibiotic use needs to be addressed; the majority of pharmacists (55.5%) and the public (61.4%) think a harmonised antibiotic appearance would reduce inappropriate use. ‘Putting the word “ANTIBIOTICS” on the packaging would improve antibiotic packaging appearance’ was the top improvement selected by pharmacists (38.3%) and public (35.3%). Pharmacists (38.9%) thought antibiotic manufacturers would be the greatest obstacle to harmonised packaging. The majority of public (70.5%) and pharmacists (85.3%) think a standardised messaging system would help reduce inappropriate antibiotic use. Both pharmacists (41.1%) and public (47%) highlighted that a standard leaflet for appropriate use could improve antibiotic use. Pharmacists (47.8%) thought that multiple stakeholders (e.g., MHRA, manufacturers, etc) would be the barriers to a standardised messaging.

Discussion/Conclusion

Inappropriate antibiotic use by individuals who re-use leftovers or share their antibiotics may result in a treatment failure and could to increase AMR. Improvements in antibiotic packaging and patient information leaflets with appropriate disposal instructions could help minimise AMR. Limitations of this study include the low number of practice and industrial pharmacist respondents compared to community and hospital pharmacists. Public and pharmacist respondents supported the wording “ANTIBIOTIC” on antibiotic packaging and a standardised leaflet covering increasing adherence and appropriate disposal of leftovers. This study warrants further evaluation with regulators, manufacturers and other key stakeholders.

References

1. HM Government. Best practice guidance on the labelling and packaging of medicines. Available from: https://www.gov.uk/government/publications/best-practice-in-the-labelling-and-packaging-of-medicines (Accessed: 10/09/22).

2. Gullberg, E., et al. Selection of resistant bacteria at very low antibiotic concentrations. PLoS Pathogens, 2011;7(7):e1002158. https://doi.org/10.1371/journal.ppat.1002158

3. Antimicrobial Resistance Collaborators. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Lancet 2022. https://doi.org/10.1016/S0140-6736(21)02724-0.

A pilot monitoring strategy for post-partum disease in an Australian dairy herd

AIMS

To design a monitoring strategy that could be applied to regular veterinary visits to dairy farms to assess the prevalence and association between health conditions (uterine disease, hyperketonaemia and suboptimal body condition score) when diagnosed and treated at 1-7 days post-calving (DPC) and then re-examined at 28-35 DPC.

METHODS

This study evaluated data from 187 high-yielding dairy cows (21 primiparous, 166 multiparous) on one South Australian dairy farm on two occasions; Visit A which was 1-7 DPC and Visit B which was 28-35 DPC. On each visit, the nature of vaginal discharge, concentration of beta-hydroxybutyrate (BOH) in blood and BCS were recorded and assigned a clinical score. This was converted to a categorical outcome denoting the presence or absence of an abnormal health event, namely metritis or endometritis, hyperketonaemia (BOH concentration ≥1.2 mm/L) and suboptimal body condition score (>0.5 from optimum score). Cows with uterine disease or hyperketonaemia at either visit were treated. The prevalence of abnormal health events at each visit was determined and the association between the prevalence of disease at Visit A and Visit B (following appropriate treatment at Visit A) was measured using regression analysis.

RESULTS

The prevalence of abnormal vaginal discharge, hyperketonaemia and suboptimal BCS at Visits A and B were 26%, 7%, 35% and 25%,16%, 33% respectively. A higher proportion of primiparous cows (Visit A: 0.86 (95% CI = 0.70-1.00); Visit B: 0.95 (95% CI = 0.86-1.00)) were found to have suboptimal BCS at both visits compared to multiparous cows (Visit A: 0.28 (95% CI = 0.20-0.35); Visit B: 0.24 (95% CI = 0.17-0.32)). A higher prevalence of hyperketonaemia at Visit B for multiparous compared to primiparous cows (19 (95% CI = 12-25)% vs. 0 (95% CI = 0-17) respectively) was identified. An increase in clinical discharge score at Visit A increased the odds of purulent vaginal discharge at Visit B (OR = 1.77 (95% CI = 1.31-2.40)). Failing to calve at target BCS was strongly associated with cows missing target BCS at Visit B (OR = 5.77 (95% CI = 2.35-13.11)) and for every unit increase in BCS at Visit A, BCS at Visit B increased by 0.40 (95% CI = 0.26-0.53).

CONCLUSIONS AND CLINICAL RELEVANCE

This study describes a pilot monitoring strategy for clinical parameters indicative of post-partum disease at 1-7 and 28-35 DPC. Determining the herd prevalence of these conditions will enable tracking of herd disease status over time.Abbreviations: BCS: Body condition score; BOH: Beta-hydroxybutyrate; DPC: Days post-calving; NEFA: Non-esterified fatty acids; SCHK: Subclinical hyperketonaemia.

'Warning: allergic to penicillin': association between penicillin allergy status in 2.3 million NHS general practice electronic health records, antibiotic prescribing and health outcomes

BACKGROUND

The prevalence of reported penicillin allergy (PenA) and the impact these records have on health outcomes in the UK general population are unknown. Without such data, justifying and planning enhanced allergy services is challenging.

OBJECTIVES

To determine: (i) prevalence of PenA records; (ii) patient characteristics associated with PenA records; and (iii) impact of PenA records on antibiotic prescribing/health outcomes in primary care.

METHODS

We carried out cross-sectional/retrospective cohort studies using patient-level data from electronic health records. Cohort study: exact matching across confounders identified as affecting PenA records. Setting: English NHS general practices between 1 April 2013 and 31 March 2014. Participants: 2.3 million adult patients. Outcome measures: prevalence of PenA, antibiotic prescribing, mortality, MRSA infection/colonization and Clostridioides difficile infection.

RESULTS

PenA prevalence was 5.9% (IQR = 3.8%-8.2%). PenA records were more common in older people, females and those with a comorbidity, and were affected by GP practice. Antibiotic prescribing varied significantly: penicillins were prescribed less frequently in those with a PenA record [relative risk (RR)  = 0.15], and macrolides (RR = 4.03), tetracyclines (RR = 1.91) nitrofurantoin (RR = 1.09), trimethoprim (RR = 1.04), cephalosporins (RR = 2.05), quinolones (RR = 2.10), clindamycin (RR = 5.47) and total number of prescriptions were increased in patients with a PenA record. Risk of re-prescription of a new antibiotic class within 28 days (RR = 1.32), MRSA infection/colonization (RR = 1.90) and death during the year subsequent to 1 April 2013 (RR = 1.08) increased in those with PenA records.

CONCLUSIONS

PenA records are common in the general population and associated with increased/altered antibiotic prescribing and worse health outcomes. We estimate that incorrect PenA records affect 2.7 million people in England. Establishing true PenA status (e.g. oral challenge testing) would allow more people to be prescribed first-line antibiotics, potentially improving health outcomes.

A national quality incentive scheme to reduce antibiotic overuse in hospitals: evaluation of perceptions and impact

Background

In 2016/2017, a financially linked antibiotic prescribing quality improvement initiative Commissioning for Quality and Innovation (AMR-CQUIN) was introduced across acute hospitals in England. This aimed for >1% reductions in DDDs/1000 admissions of total antibiotics, piperacillin/tazobactam and carbapenems compared with 2013/2014 and improved review of empirical antibiotic prescriptions.

Objectives

To assess perceptions of staff leading antimicrobial stewardship activity regarding the AMR-CQUIN, the investments made by hospitals to achieve it and how these related to achieving reductions in antibiotic use.

Methods

We invited antimicrobial stewardship leads at acute hospitals across England to complete a web-based survey. Antibiotic prescribing data were downloaded from the PHE Antimicrobial Resistance Local Indicators resource.

Results

Responses were received from 116/155 (75%) acute hospitals. Owing to yearly increases in antibiotic use, most trusts needed to make >5% reductions in antibiotic consumption to achieve the AMR-CQUIN goal of 1% reduction. Additional funding was made available at 23/113 (20%) trusts and, in 18 (78%), this was <10% of the AMR-CQUIN value. Nationally, the annual trend for increased antibiotic use reversed in 2016/2017. In 2014/2015, year-on-year changes were +3.7% (IQR -0.8%, +8.4%), +9.4% (+0.2%, +19.5%) and +5.8% (-6.2%, +18.2%) for total antibiotics, piperacillin/tazobactam and carbapenems, respectively, and +0.1% (-5.4%, +4.0%), -4.8% (-16.9%, +3.2%) and -8.0% (-20.2%, +4.0%) in 2016/2017. Hospitals where staff believed they could reduce antibiotic use were more likely to do so (P < 0.001).

Conclusions

Introducing the AMR-CQUIN was associated with a reduction in antibiotic use. For individual hospitals, achieving the AMR-CQUIN was associated with favourable perceptions of staff and not availability of funding.

Is the rate of revision of 36 mm metal-on-metal total hip arthroplasties with Pinnacle acetabular components related to the year of the initial operation? an interrupted time-series analysis using data from the National Joint Registry for England and Wales

AIMS

The aim of this study was to determine whether the rates of revision for metal-on-metal (MoM) total hip arthroplasties (THAs) with Pinnacle components varied according to the year of the initial operation, and compare these with the rates of revision for other designs of MoM THA.

PATIENTS AND METHODS

Data from the National Joint Registry for England and Wales included 36 mm MoM THAs with Pinnacle acetabular components which were undertaken between 2003 and 2012 with follow-up for at least five years (n = 10 776) and a control group of other MoM THAs (n = 13 817). The effect of the year of the primary operation on all-cause rates of revision was assessed using Cox regression and interrupted time-series analysis.

RESULTS

For MoM THAs involving Pinnacle components, those undertaken between 2007 and 2012 had higher rates of revision compared with those undertaken between 2004 and 2006 (hazard ratio (HR) 2.01; 95% confidence interval (CI) 1.57 to 2.57; p < 0.001). For THAs undertaken during and after 2007, the number of revisions per 1000 implant-years at risk significantly increased by 5.20 (95% CI 0.52 to 9.89; p = 0.033) compared with those undertaken before this time. In the control group, THAs undertaken between 2007 and 2012 also had higher rates of revision (HR 1.77; 95% CI 1.49 to 2.10; p < 0.001), with revisions per 1000 implant-years for those undertaken during and after 2007 significantly increasing by 6.13 (95% CI 1.42 to 10.83; p = 0.016).

CONCLUSION

The five-year revision rates were significantly increased for all primary MoM THAs undertaken from 2007 onwards. Contrary to recent reports, this finding was not specific to those involving Pinnacle acetabular components and may be explained by increased surveillance and recent lowering of the threshold for revision. Cite this article: Bone Joint J 2018;100-B:33-41.

Fatal pulmonary embolism following elective total knee replacement using aspirin in multi-modal prophylaxis - A 12year study

BACKGROUND

The National Institute for Health and Clinical Excellence (NICE) has issued guidelines on which thromboprophylaxis regimens are suitable following lower limb arthroplasty. Aspirin is not a recommended agent despite being accepted in orthopaedic guidelines elsewhere. We assessed the incidence of fatal pulmonary embolism (PE) and all-cause mortality following elective primary total knee replacement (TKR) with a standardised multi-modal prophylaxis regime in a large teaching district general hospital.

METHODS

We utilised a prospective audit database to identify those that had died within 42 and 90days postoperatively. Data from April 2000 to 2012 were analysed for 42 and 90day mortality rates. There were a total of 8277 elective primary TKR performed over the 12year period. The multi-modal prophylaxis regimen used unless contraindicated for all patients included 75mg aspirin once daily for four weeks. Case note review ascertained the causes of death. Where a patient had been referred to the coroner, they were contacted for post mortem results.

RESULTS

The mortality rates at 42 and 90days were 0.36 and 0.46%. There was one fatal PE within 42days of surgery (0.01%) who was taking enoxaparin because of aspirin intolerance. Two fatal PE's occurred at 48 and 57days post-operatively (0.02%). The leading cause of death was myocardial infarction (0.13%).

CONCLUSIONS

Fatal PE following elective TKR with a multi-modal prophylaxis regime is a very rare cause of mortality.

A feasibility service evaluation of screening and treatment of group A streptococcal pharyngitis in community pharmacies

OBJECTIVES

The UK 5 year antimicrobial resistance strategy recognizes the role of point-of-care diagnostics to identify where antimicrobials are required, as well as to assess the appropriateness of the diagnosis and treatment. A sore throat test-and-treat service was introduced in 35 community pharmacies across two localities in England during 2014-15.

METHODS

Trained pharmacy staff assessed patients presenting with a sore throat using the Centor scoring system and patients meeting three or all four of the criteria were offered a throat swab test for Streptococcus pyogenes, Lancefield group A streptococci. Patients with a positive throat swab test were offered antibiotic treatment.

RESULTS

Following screening by pharmacy staff, 149/367 (40.6%) patients were eligible for throat swab testing. Of these, only 36/149 (24.2%) were positive for group A streptococci. Antibiotics were supplied to 9.8% (n = 36/367) of all patients accessing the service. Just under half of patients that were not showing signs of a bacterial infection (60/123, 48.8%) would have gone to their general practitioner if the service had not been available.

CONCLUSIONS

This study has shown that it is feasible to deliver a community-pharmacy-based screening and treatment service using point-of-care testing. This type of service has the potential to support the antimicrobial resistance agenda by reducing unnecessary antibiotic use and inappropriate antibiotic consumption.

The impact of the introduction of fidaxomicin on the management of Clostridium difficile infection in seven NHS secondary care hospitals in England: a series of local service evaluations

Clostridium difficile infection (CDI) is associated with high mortality. Reducing incidence is a priority for patients, clinicians, the National Health Service (NHS) and Public Health England alike. In June 2012, fidaxomicin (FDX) was launched for the treatment of adults with CDI. The objective of this evaluation was to collect robust real-world data to understand the effectiveness of FDX in routine practice. In seven hospitals introducing FDX between July 2012 and July 2013, data were collected retrospectively from medical records on CDI episodes occurring 12 months before/after the introduction of FDX. All hospitalised patients aged ≥18 years with primary CDI (diarrhoea with presence of toxin A/B without a previous CDI in the previous 3 months) were included. Recurrence was defined as in-patient diarrhoea re-emergence requiring treatment any time within 3 months after the first episode. Each hospital had a different protocol for the use of FDX. In hospitals A and B, where FDX was used first line for all primary and recurrent episodes, the recurrence rate reduced from 10.6 % to 3.1 % and from 16.3 % to 3.1 %, with a significant difference in 28-day mortality from 18.2 % to 3.1 % (p < 0.05) and 17.3 % to 6.3 % (p < 0.05) for hospitals A and B, respectively. In hospitals using FDX in selected patients only, the changes in recurrence rates and mortality were less marked. The pattern of adoption of FDX appears to affect its impact on CDI outcome, with maximum reduction in recurrence and all-cause mortality where it is used as first-line treatment.

An international cross-sectional survey of antimicrobial stewardship programmes in hospitals

OBJECTIVES

To report the extent and components of global efforts in antimicrobial stewardship (AMS) in hospitals.

METHODS

An Internet-based survey comprising 43 questions was disseminated worldwide in 2012.

RESULTS

Responses were received from 660 hospitals in 67 countries: Africa, 44; Asia, 50; Europe, 361; North America, 72; Oceania, 30; and South and Central America, 103. National AMS standards existed in 52% of countries, 4% were planning them and 58% had an AMS programme. The main barriers to implementing AMS programmes were perceived to be a lack of funding or personnel, a lack of information technology and prescriber opposition. In hospitals with an existing AMS programme, AMS rounds existed in 64%; 81% restricted antimicrobials (carbapenems, 74.3%; quinolones, 64%; and cephalosporins, 58%); and 85% reported antimicrobial usage, with 55% linking data to resistance rates and 49% linking data to infection rates. Only 20% had electronic prescribing for all patients. A total of 89% of programmes educated their medical, nursing and pharmacy staff on AMS. Of the hospitals, 38% had formally reviewed their AMS programme: reductions were reported by 96% of hospitals for inappropriate prescribing, 86% for broad-spectrum antibiotic use, 80% for expenditure, 71% for healthcare-acquired infections, 65% for length of stay or mortality and 58% for bacterial resistance.

CONCLUSIONS

The worldwide development and implementation of AMS programmes varies considerably. Our results should inform and encourage the further evaluation of this with a view to promoting a worldwide stewardship framework. The prospective measurement of well-defined outcomes of the impact of these programmes remains a significant challenge.

Knowledge, attitudes, and beliefs of French medical students about antibiotic prescribing and resistance

OBJECTIVES

We had for aim to learn about medical students' knowledge and perspectives on antibiotic prescribing and bacterial resistance.

METHODS

Penultimate and final year students at a French medical school were invited to participate in an anonymous online survey in summer 2012.

RESULTS

The response rate was 20% (60/297). Penultimate and final year students gave similar answers. Students felt more confident in diagnosing an infection, and less confident in choosing the correct dose and interval of antibiotic administration. Seventy-nine percent of students wanted more training on antibiotic treatments. Sixty-nine percent of students knew that antibiotic prescriptions were inappropriate or unnecessary in 21-60% of the cases, and 95% believed that these prescriptions were unethical. Only 27% knew that more than 80% of antibiotic prescriptions were made in community practice. Students believed that the most important causes of resistance were that too many prescriptions were made and broad-spectrum antibiotic use; 27% believed poor hand hygiene was "not at all important". Ninety-four percent believed resistance was a national problem, and 69% mentioned it as a problem in their hospital. Sixty-three percent thought that the antibiotics they would prescribe would contribute to resistance, and 96% thought resistance would be a greater problem in the future. Twenty-two percent knew MRSA bacteremia rates had decreased over the past decade in France.

CONCLUSIONS

Medical students are aware that antibiotic resistance is a current and growing problem. They would like more training on antibiotic selection.

Environmental persistence of organic pollutants: guidance for development and review of POP risk profiles

Environmental persistence is an important property that can enhance the potential of a chemical substance to exert adverse effects and be transported to remote environments. The persistence of organic compounds is governed by the rates at which they are removed by biological and chemical processes, such as biodegradation, hydrolysis, atmospheric oxidation, and photolysis. The persistence workgroup in a recent Society of Environmental Toxicology and Chemistry (SETAC) Pellston workshop (Pensacola, FL, USA, January 2008) focused on evaluating persistence of organic compounds in environmental media (air, water, soil, sediment) in terms of their single-medium degradation half-lives. The primary aim was to provide guidance to authors and reviewers of chemical dossiers for persistent organic pollutants (POPs) and persistent, bioaccumulative, and toxic substances (PBTs) proposed for action. A second objective was to provide a summary of the current state of the science with respect to POP fate assessment. Assessing the persistence of chemical substances in the environment is not straightforward. A common misconception is that, like many chemical properties, environmental persistence is an inherent property of the substance and can be readily measured. In fact, rates of degradation of a substance in the environment are determined by a combination of substance-specific properties and environmental conditions. This article addresses how persistence can be evaluated based on an assortment of supporting information. Special attention is given to several critical issues, including transformation products, nonextractable residues, and treatment of uncertainty and conflicting data as part of a weight-of-evidence assessment.

Comparison of image quality and radiation dose between fixed tube current and combined automatic tube current modulation in craniocervical CT angiography

BACKGROUND AND PURPOSE

The combined automatic tube current modulation (ATCM) technique adapts and modulates the x-ray tube current in the x-y-z axis according to the patient's individual anatomy. We compared image quality and radiation dose of the combined ATCM technique with those of a fixed tube current (FTC) technique in craniocervical CT angiography performed with a 64-section multidetector row CT (MDCT) system.

MATERIALS AND METHODS

A retrospective review of craniocervical CT angiograms (CTAs) by using combined ATCM (n = 25) and FTC techniques (n = 25) was performed. Other CTA parameters, such as kilovolt (peak), matrix size, FOV, section thickness, pitch, contrast agent, and contrast injection techniques, were held constant. We recorded objective image noise in the muscles at 2 anatomic levels: radiation exposure doses (CT dose index volume and dose-length product); and subjective image quality parameters, such as vascular delineation of various arterial vessels, visibility of small arterial detail, image artifacts, and certainty of diagnosis. The Mann-Whitney U test was used for statistical analysis.

RESULTS

No significant difference was detected in subjective image quality parameters between the FTC and combined ATCM techniques. Most subjects in both study groups (49/50, 98%) had acceptable subjective artifacts. The objective image noise values at shoulder level did not show a significant difference, but the noise value at the upper neck was higher with the combined ATCM (P < .05) technique. Significant reduction in radiation dose (18% reduction) was noted with the combined ATCM technique (P < .05).

CONCLUSIONS

The combined ATCM technique for craniocervical CTA performed at 64-section MDCT substantially reduced radiation exposure dose but maintained diagnostic image quality.

A clinical and genetic study of the Say/Barber/Biesecker/Young-Simpson type of Ohdo syndrome

We report a series of eight patients with the Say/Barber/Biesecker/Young-Simpson (SBBYS) type of Ohdo syndrome, which is the largest cohort described to date. We expand on the type, frequency and severity of the clinical characteristics in this condition; comment on the natural history of Ohdo syndrome and further refine previously published diagnostic criteria. Cytogenetic investigations and microarray CGH analysis undertaken in this cohort of patients failed to identify a chromosomal aetiology. It remains possible that this rare condition is heterogeneous and therefore caution must be undertaken during counselling until the underlying genetic mechanism(s) is (are) identified.

Randomised, placebo controlled trial of nebulised furosemide for breathlessness in patients with cancer

BACKGROUND

Breathlessness is a common and difficult symptom to treat in patients with cancer. Case reports suggest that nebulised furosemide can relieve breathlessness in such patients but few data are available.

METHOD

Patients with primary or secondary lung cancer and a Dyspnoea Exertion Scale score of >or=3 were recruited. Following familiarisation, patients received either nebulised furosemide 40 mg or nebulised 0.9% saline under double blind conditions or no treatment, in random order on 3 consecutive days. Patients undertook number reading and arm exercise tests to assess breathlessness and its impact, and were asked to report subjective benefit and any preference between nebulised treatments.

RESULTS

15 patients took part. There were no differences between furosemide, saline and no treatment in the outcomes of the number reading test (eg, mean number read per breath was 6.7, 6.4 and 6.7, respectively) or arm exercise test (eg, mean Borg score at maximum equivalent workload was 2.3, 2.5 and 2.7, respectively). No adverse effects were reported, although there was a small fall in forced expiratory volume in 1 s and forced vital capacity following saline. Six patients considered that their breathlessness improved with nebulised treatment, three preferring saline, one furosemide and two reporting they were of equal benefit.

CONCLUSIONS

Our findings do not support a beneficial effect from nebulised furosemide in patients with cancer related breathlessness. Listed on the National Research Register (N0170118249) and the UK Clinical Research Network Portfolio Database (1428).