Impact of molecular ciprofloxacin resistance testing in management of gonorrhoea in a large urban clinic.

OBJECTIVES: Antibiotic resistance in gonorrhoea is of significant public health concern with the emergence of resistance to last-line therapies such as ceftriaxone. Despite around half of Neisseria gonorrhoeae isolates tested in the UK being susceptible to ciprofloxacin, very little ciprofloxacin is used in clinical practice. Testing for the S91F mutation associated with ciprofloxacin resistance is now available in CE-marked assays and may reduce the requirement for ceftriaxone, but many patients are treated empirically, or as sexual contacts, which may limit any benefit. We describe the real-world impact of such testing on antimicrobial use and clinical outcomes in people found to have gonorrhoea in a large urban UK sexual health clinic. METHODS: Molecular ciprofloxacin resistance testing (ResistancePlus GC assay (SpeeDx)) was undertaken as an additional test after initial diagnosis (m2000 Realtime CT/NG assay (Abbott Molecular)) in those not already known to have had antimicrobial treatment. Data from a 6-month period (from March to September 2022) were analysed to determine treatment choice and treatment outcome. RESULTS: A total of 998 clinical samples tested positive for N. gonorrhoeae in 682 episodes of infection. Of the 560 (56%) samples eligible for resistance testing, 269 (48.0%) were reported as wild-type, 180 (32.1%) were predicted to be resistant, 63 (11.3%) had an indeterminate resistance profile, and in 48 (8.6%) samples, N. gonorrhoeae was not detected. Ciprofloxacin was prescribed in 172 (75%) of 228 episodes in which the wild-type strain was detected. Four (2%) of those treated with ciprofloxacin had a positive test-of-cure sample by NAAT, with no reinfection risk. All four had ciprofloxacin-susceptible infection by phenotypic antimicrobial susceptibility testing. CONCLUSIONS: In routine practice in a large UK clinic, molecular ciprofloxacin resistance testing led to a significant shift in antibiotic use, reducing use of ceftriaxone. Testing can be targeted to reduce unnecessary additional testing. Longer term impact on antimicrobial resistance requires ongoing surveillance.

Education of parents in Pavlik harness application for developmental dysplasia of the hip using a validated simulated learning module.

BACKGROUND: The Pavlik harness is the most common initial treatment for developmental dysplasia of the hip worldwide. During treatment, parents are required to re-apply the harness at home. Teaching parents how to apply the harness is therefore paramount to success. While simulated learning for medical training is commonplace, it has not yet been trialed in teaching parents how to apply a Pavlik harness. METHODS: A group of parents underwent a simulated learning module for Pavlik harness application. Parents were evaluated pre- and post-exposure and at one month after testing. A validated objective structured assessment of technical skill (OSATS) and a global rating scale (GRS) specific to Pavlik harness application were used for evaluation. A control group of parents was also tested at both time points. A clinical expert group was used to determine competency. ANOVA and t tests were used to assess differences between groups and over time. RESULTS: Parent scores on the OSATS improved to the level of expert clinicians both immediately post-intervention and at retention testing. However, on the GRS, only half were considered competent due to their inability to achieve the required hip positions. The control group did not improve nor were they considered competent. CONCLUSIONS: The use of a simulated learning module improves both the confidence and skill level of parents in the application of the Pavlik harness. However, the challenges parents face in understanding the more detailed subtleties of medical care suggest that they still require an appropriate level of supervision by clinicians to ensure effective treatment.

Skill Acquisition and Retention Following Simulation-Based Training in Pavlik Harness Application.

BACKGROUND: Simulation-based learning is increasingly prevalent in many surgical training programs, as medical education moves toward competency-based curricula. In orthopaedic surgery, developmental dysplasia of the hip is a commonly treated condition, where the standard of care for patients less than six months of age is an orthotic device such as the Pavlik harness. However, despite widespread use of the Pavlik harness and the potential complications that may arise from inappropriate application, we know of no previously described formal training curriculum for Pavlik harness application. METHODS: We developed a video and model-based simulation learning module for Pavlik harness application. Two novice groups (residents and allied health professionals) were exposed to the module and, at pre-intervention, post-intervention, and retention testing, were evaluated on their ability to apply a Pavlik harness to the model. Evaluations were completed using a previously validated Objective Structured Assessment of Technical Skills (OSATS) and a global rating scale (GRS) specific to Pavlik harness application. A control group that did not undergo the module was also evaluated at two time points to determine if exposure to the Pavlik harness alone would affect skill acquisition. All groups were compared with a group of clinical experts, whose scores were used as a competency benchmark. Statistical analysis of skill acquisition and retention was conducted using t tests and analysis of variance (ANOVA). RESULTS: Exposure to the learning module improved resident and allied health professionals' competency in applying a Pavlik harness (p < 0.05) to the level of the expert clinicians, and this level of competency was retained one month after exposure to the module. Control subjects who were not exposed to the module did not improve, nor did they achieve competency. CONCLUSIONS: The simulation-based learning module was shown to be an effective tool for teaching the application of a Pavlik harness, and learners demonstrated retainable skills post-intervention. This learning module can form the cornerstone of formal teaching of Pavlik harness application for developmental dysplasia of the hip.

A Reliable and Valid Objective Structured Assessment of Technical Skill for the Application of a Pavlik Harness Based on International Expert Consensus.

BACKGROUND: The use of competency-based training is increasing in medical education as it offers individualized learning opportunities to master required skills. Inherent to this method of teaching is the need for standardized and objective assessments of skill mastery. In orthopaedic surgery, educational programs have focused on surgical skills with lesser emphasis on nonoperative techniques. Accordingly, formal evaluation tools specific to Pavlik Harness application do not exist, despite its widespread use and potential complications from inappropriate application. This study sought to develop a reliable and valid evaluation tool based on international expert consensus to standardize and evaluate Pavlik Harness application for developmental dysplasia of the hip. METHODS: Consensus was sought from 10 content experts using Delphi methodology. Resulting items formed the Objective Structured Assessment of Technical Skill (OSATS). Thirty-five participants were selected into 3 a priori groups (expert, intermediate and novice) based on Pavlik Harness experience. On 2 occasions, 3 content experts assessed randomized and deidentified videotapes of each participant applying a Pavlik Harness to an infant model using the OSATS and global rating scales (GRS). The reliability and validity of the OSATS was determined with intraclass (ICC) and Pearson correlations and analysis of variance (ANOVA). RESULTS: Consensus was obtained after 2 rounds of structured surveying and resulted in a 25-item OSATS. The reliability of the OSATS was excellent with an ICC of 0.96 for interrater and 0.98 for test-retest reliability. Construct validity was excellent with high correlations between OSATS and GRS (>0.90). In addition, the OSATS discriminated between expert, intermediate, and novice users. CONCLUSIONS: We have developed a competency-based evaluation tool for Pavlik Harness application based on consensus from international experts. The OSATS has been shown to be a reliable and valid method for assessing Pavlik Harness application that can discriminate between expert, intermediate, and novice users. LEVEL OF EVIDENCE: Level II.