Ethnic variation in outcome of people hospitalised during the first COVID-19 epidemic wave in Wales (UK): an analysis of national surveillance data using Onomap, a name-based ethnicity classification tool.

OBJECTIVE: To identify ethnic differences in proportion positive for SARS-CoV-2, and proportion hospitalised, proportion admitted to intensive care and proportion died in hospital with COVID-19 during the first epidemic wave in Wales. DESIGN: Descriptive analysis of 76 503 SARS-CoV-2 tests carried out in Wales to 31 May 2020. Cohort study of 4046 individuals hospitalised with confirmed COVID-19 between 1 March and 31 May. In both analyses, ethnicity was assigned using a name-based classifier. SETTING: Wales (UK). PRIMARY AND SECONDARY OUTCOMES: Admission to an intensive care unit following hospitalisation with a positive SARS-CoV-2 PCR test. Death within 28 days of a positive SARS-CoV-2 PCR test. RESULTS: Using a name-based ethnicity classifier, we found a higher proportion of black, Asian and ethnic minority people tested for SARS-CoV-2 by PCR tested positive, compared with those classified as white. Hospitalised black, Asian and minority ethnic cases were younger (median age 53 compared with 76 years; p<0.01) and more likely to be admitted to intensive care. Bangladeshi (adjusted OR (aOR): 9.80, 95% CI 1.21 to 79.40) and 'white - other than British or Irish' (aOR: 1.99, 95% CI 1.15 to 3.44) ethnic groups were most likely to be admitted to intensive care unit. In Wales, older age (aOR for over 70 years: 10.29, 95% CI 6.78 to 15.64) and male gender (aOR: 1.38, 95% CI 1.19 to 1.59), but not ethnicity, were associated with death in hospitalised patients. CONCLUSIONS: This study adds to the growing evidence that ethnic minorities are disproportionately affected by COVID-19. During the first COVID-19 epidemic wave in Wales, although ethnic minority populations were less likely to be tested and less likely to be hospitalised, those that did attend hospital were younger and more likely to be admitted to intensive care. Primary, secondary and tertiary COVID-19 prevention should target ethnic minority communities in Wales.

Understanding the Influence of Socioeconomic Environment on Paediatric Antiretroviral Treatment Coverage: Towards Closing Treatment Gaps in Sub-Saharan Africa.

OBJECTIVE: Many sub-Saharan African countries have massively scaled-up their antiretroviral treatment (ART) programmes, but many national programmes still show large gaps in paediatric ART coverage making it challenging to reduce AIDS-related deaths among HIV-infected children. We sought to identify enablers of paediatric ART coverage in Africa by examining the relationship between paediatric ART coverage and socioeconomic parameters measured at the population level so as to accelerate reaching the 90-90-90 targets. METHODS: Ecological analyses of paediatric ART coverage and socioeconomic indicators were performed. The data were obtained from the United Nations agencies and Forum for a new World Governance reports for the 21 Global Plan priority countries in Africa with highest burden of mother-to-child HIV transmission. Spearman's correlation and median regression were utilized to explore possible enablers of paediatric ART coverage. RESULTS: Factors associated with paediatric ART coverage included adult literacy (r=0.6, p=0.004), effective governance (r=0.6, p=0.003), virology testing by 2 months of age (r=0.9, p=0.001), density of healthcare workers per 10,000 population (r=0.6, p=0.007), and government expenditure on health (r=0.5, p=0.046). The paediatric ART coverage had a significant inverse relationship with the national mother-to-child transmission (MTCT) rate (r=-0.9, p<0.001) and gender inequality index (r=-0.6, p=0.006). Paediatric ART coverage had no relationship with poverty and HIV stigma indices. CONCLUSIONS: Low paediatric ART coverage continues to hamper progress towards eliminating AIDS-related deaths in HIV-infected children. Achieving this requires full commitment to a broad range of socioeconomic development goals.

Modelling study to estimate the health burden of foodborne diseases: cases, general practice consultations and hospitalisations in the UK, 2009.

OBJECTIVE: To generate estimates of the burden of UK-acquired foodborne disease accounting for uncertainty. DESIGN: A modelling study combining data from national public health surveillance systems for laboratory-confirmed infectious intestinal disease (IID) and outbreaks of foodborne disease and 2 prospective, population-based studies of IID in the community. The underlying data sets covered the time period 1993-2008. We used Monte Carlo simulation and a Bayesian approach, using a systematic review to generate Bayesian priors. We calculated point estimates with 95% credible intervals (CrI). SETTING: UK, 2009. OUTCOME MEASURES: Pathogen-specific estimates of the number of cases, general practice (GP) consultations and hospitalisations for foodborne disease in the UK in 2009. RESULTS: Bayesian approaches gave slightly more conservative estimates of overall health burden (∼511 000 cases vs 566 000 cases). Campylobacter is the most common foodborne pathogen, causing 280 400 (95% CrI 182 503-435 693) food-related cases and 38 860 (95% CrI 27 160-55 610) GP consultations annually. Despite this, there are only around 562 (95% CrI 189-1330) food-related hospital admissions due to Campylobacter, reflecting relatively low disease severity. Salmonella causes the largest number of hospitalisations, an estimated 2490 admissions (95% CrI 607-9631), closely followed by Escherichia coli O157 with 2233 admissions (95% CrI 170-32 159). Other common causes of foodborne disease include Clostridium perfringens, with an estimated 79 570 cases annually (95% CrI 30 700-211 298) and norovirus with 74 100 cases (95% CrI 61 150-89 660). Other viruses and protozoa ranked much lower as causes of foodborne disease. CONCLUSIONS: The 3 models yielded similar estimates of the burden of foodborne illness in the UK and show that continued reductions in Campylobacter, Salmonella, E. coli O157, C. perfringens and norovirus are needed to mitigate the impact of foodborne disease.

Parental views on childhood vaccination against viral gastroenteritis-a qualitative interview study.

BACKGROUND: Gastroenteritis (GE) causes significant morbidity, especially in young children. A vaccine against rotavirus, a common cause of viral GE (vGE), was added to the childhood immunization schedule in the UK in July 2013 and further related vaccines are under development. AIM: To explore parents' beliefs about vGE and their attitudes towards vaccinating. DESIGN AND SETTING: Qualitative interview study with parents of children who had recently experienced an episode of GE. METHOD: Twenty-eight semi-structured interviews were conducted over the phone with parents. Interviews were audio-recorded, transcribed and analysed using standard thematic approaches. RESULTS: Parents varied in their perception of the threat posed by GE, and parents who did not perceive GE as serious were less enthusiastic about vaccines. Other parents were supportive of vaccines in general and considered benefits to their child, their family and the wider community. Many parents said that they lacked knowledge about efficacy and effectiveness of GE vaccines but their underlying belief about the seriousness of illness motivated their attitudes. CONCLUSION: Acceptability of GE vaccines to parents could be improved by providing more information on both the burden of illness and the impact of rotavirus vaccine in other comparable countries.

The influence of children's day care on antibiotic seeking: a mixed methods study.

BACKGROUND: Preschool-aged children are the highest consumers of antibiotics, but consult mainly for viral infections. Little is known about how day care, which is common in this age group, influences primary care consulting and treatment-seeking behaviours. AIM: To investigate daycare providers' approaches to excluding and/or readmitting children with infections, and the consequences for parents' consulting and antibiotic-seeking behaviours. DESIGN AND SETTING: Cross-sectional survey, document analysis, and qualitative interviews of daycare providers and parents in South East Wales, UK. METHOD: A total of 328 daycare providers were asked to complete a survey about infection exclusion practices and to provide a copy of their sickness exclusion policy. Next, 52 semi-structured interviews were conducted with purposively selected questionnaire responders and parents using their services. Questionnaire responses underwent bivariate analysis, policies underwent document analysis, and interviews were thematically analysed using constant comparison methods. RESULTS: In total 217 out of 328 (66%) daycare providers responded; 82 out of 199 (41%) reported advising parents that their child may need antibiotics and 199 out of 214 (93%) reported advising general practice consultations. Interviews confirmed that such advice was routine, and beliefs about antibiotic indications often went against clinical guidelines: 24% (n = 136) of sickness exclusion policies mentioning infections made at least one non-evidence-based indication for 'treatment' or antibiotics. Parent interviews revealed that negotiating daycare requirements lowered thresholds for consulting and encouraged antibiotic seeking. CONCLUSION: Daycare providers encourage parents to consult general practice and seek antibiotics through non-evidence-based policies and practices. Parents' perceptions of daycare providers' requirements override their own beliefs of when it is appropriate to consult and seek treatment.

Why some children hospitalized for pneumonia do not consult with a general practitioner before the day of hospitalization.

BACKGROUND: Early consultation in primary care may provide an opportunity for early intervention in children developing pneumonia, but little is known about why some children do not consult a general practitioner (GP) before hospitalization. OBJECTIVES: To identify differences between children who consulted a GP and children who did not consult a GP before the day of hospital presentation with pneumonia or empyema. METHODS: Carers of children aged six months to 16 years presenting to hospital with pneumonia or empyema completed a questionnaire, with a subset participating in an interview to identify physical, organizational and psychological barriers to consultation. Responses from those who had consulted a GP before the day of hospital presentation were compared with those who had not on a range of medical, social and environmental variables. RESULTS: Fifty seven (38%) of 151 participants had not consulted a GP before the day of hospital presentation. On multivariate analysis, illness duration ≥ 3 days (odds ratio [OR] 4.36, 95% confidence interval [CI]: 1.67-11.39), prior antibiotic use (OR: 10.35, 95% CI: 2.16-49.55) and home ownership (OR: 3.17, 95% CI: 1.07-9.37) were significantly associated with early GP consultation (P < 0.05). Interviews with 28 carers whose children had not seen a GP before the day of presentation revealed that most had not considered it and/or did not think their child's initial symptoms were serious or unusual; 11 (39.3%) had considered consulting a GP but reported barriers to access. CONCLUSION: Lack of early GP consultation was strongly associated with rapid evolution of pneumonia.

Carers' perspectives on the presentation of community-acquired pneumonia and empyema in children: a case series.

OBJECTIVE: To describe carers' perceptions of the development and presentation of community-acquired pneumonia or empyema in their children. DESIGN: Case series. SETTING: Seven hospitals with paediatric inpatient units in South Wales, UK. PARTICIPANTS: Carers of 79 children aged 6 months to 16 years assessed in hospital between October 2008 and September 2009 with radiographic, community-acquired pneumonia or empyema. METHODS: Carers were recruited in hospital and participated in a structured face-to-face or telephone interview about the history and presenting features of their children's illnesses. Responses to open questions were initially coded very finely and then grouped into common themes. Cases were classified into two age groups: 3 or more years and under 3 years. RESULTS: The reported median duration of illness from onset until the index hospital presentation was 4 days (IQR 2-9 days). Pain in the torso was reported in 84% of cases aged 3 or more years and was the most common cause for carer concern in this age group. According to carer accounts, clinicians sometimes misjudged the origin of this pain. Almost all carers reported something unusual about the index illness that had particularly concerned them-mostly non-specific physical symptoms and behavioural changes. CONCLUSIONS: Pain in the torso and carer concerns about unusual symptoms in their child may provide valuable additional information in a clinician's assessment of the risk of pneumonia in primary care. Further research is needed to confirm the diagnostic value of these features.

Completeness of infectious disease notification in the United Kingdom: A systematic review.

OBJECTIVES: Infectious disease legislation in the United Kingdom has recently changed. Our aim was to provide a baseline against which to assess the impact of these changes by synthesising current knowledge on completeness of notification and on factors associated with better reporting rates. METHODS: We systematically reviewed the literature for studies reporting completeness of reporting of notifiable infectious diseases in the United Kingdom over the past 35 years. RESULTS: Altogether, 46 studies met our search criteria. Reporting completeness varied from 3% to 95% and was most strongly correlated with the disease being reported. Median reporting completeness was 73% (range 6%-93%) for tuberculosis, 65% (range 40%-95%) for meningococcal disease, and 40% (range 3%-87%) for other diseases (Kruskal-Wallis test, p < 0.05). Reporting completeness did not change for either tuberculosis or meningococcal disease over the period studied. In multivariate analysis, none of the factors examined (study size, study time period, number of data sources used to assess completeness, uncorrected or corrected study design) were significantly associated with reporting completeness. CONCLUSION: Reporting completeness has not improved over the past three decades. It remains sub-optimal even for diseases which are under enhanced surveillance or are of significant public health importance.

Effectiveness of multifaceted educational programme to reduce antibiotic dispensing in primary care: practice based randomised controlled trial.

OBJECTIVE: To evaluate the effectiveness and costs of a multifaceted flexible educational programme aimed at reducing antibiotic dispensing at the practice level in primary care. DESIGN: Randomised controlled trial with general practices as the unit of randomisation and analysis. Clinicians and researchers were blinded to group allocation until after randomisation. SETTING: 68 general practices with about 480,000 patients in Wales, United Kingdom. PARTICIPANTS: 34 practices were randomised to receive the educational programme and 34 practices to be controls. 139 clinicians from the intervention practices and 124 from control practices had agreed to participate before randomisation. Practice level data covering all the clinicians in the 68 practices were analysed. INTERVENTIONS: Intervention practices followed the Stemming the Tide of Antibiotic Resistance (STAR) educational programme, which included a practice based seminar reflecting on the practices' own dispensing and resistance data, online educational elements, and practising consulting skills in routine care. Control practices provided usual care. MAIN OUTCOME MEASURES: Total numbers of oral antibiotic items dispensed for all causes per 1000 practice patients in the year after the intervention, adjusted for the previous year's dispensing. Secondary outcomes included reconsultations, admissions to hospital for selected causes, and costs. RESULTS: The rate of oral antibiotic dispensing (items per 1000 registered patients) decreased by 14.1 in the intervention group but increased by 12.1 in the control group, a net difference of 26.1. After adjustment for baseline dispensing rate, this amounted to a 4.2% (95% confidence interval 0.6% to 7.7%) reduction in total oral antibiotic dispensing for the year in the intervention group relative to the control group (P=0.02). Reductions were found for all classes of antibiotics other than penicillinase-resistant penicillins but were largest and significant individually for phenoxymethylpenicillins (penicillin V) (7.3%, 0.4% to 13.7%) and macrolides (7.7%, 1.1% to 13.8%). There were no significant differences between intervention and control practices in the number of admissions to hospital or in reconsultations for a respiratory tract infection within seven days of an index consultation. The mean cost of the programme was £2923 (€3491, $4572) per practice (SD £1187). There was a 5.5% reduction in the cost of dispensed antibiotics in the intervention group compared with the control group (-0.4% to 11.4%), equivalent to a reduction of about £830 a year for an average intervention practice. CONCLUSION: The STAR educational programme led to reductions in all cause oral antibiotic dispensing over the subsequent year with no significant change in admissions to hospital, reconsultations, or costs. Trial registration ISRCT No 63355948.

Paediatric pneumonia or empyema and prior antibiotic use in primary care: a case-control study.

OBJECTIVES: To investigate the association between hospital presentation for paediatric pneumonia or empyema and prior antibiotic use for respiratory tract infection (RTI). METHODS: Case-control study of children aged 6 months to 16 years presenting to hospital with radiographic evidence of pneumonia or empyema and a history of general practitioner (GP) consultation for the index illness. Cases were recruited from seven hospitals in South Wales between October 2008 and December 2009. Controls were children from the same age group who were diagnosed with an uncomplicated RTI in general practice in the same area and at a similar time of year. Primary data were collected from carers by a self-complete questionnaire, with a subsample compared against general practice records. RESULTS: We recruited 89 eligible cases and 166 eligible controls. Cases were less likely than controls to have been prescribed antibiotics at the first GP consultation for the index illness [odds ratio (OR) 0.53; 95% confidence interval (95% CI) 0.31-0.90]. Stratified analyses revealed that this association was limited to children who consulted a GP <3 days after illness onset (OR 0.23; 95% CI 0.10-0.50). Cases were also less likely to have taken antibiotics before the date of index hospital presentation, but this finding was not statistically significant after adjustment for confounding factors (adjusted OR 0.84; 95% CI 0.47-1.49). CONCLUSIONS: Antibiotics prescribed at the first GP consultation for an RTI may protect against subsequent hospital presentation for pneumonia or empyema in some children. Given the strong rationale against unnecessary antibiotic prescribing, further research is needed to identify which children are most likely to benefit from early antibiotic treatment.

Longitudinal study of infectious intestinal disease in the UK (IID2 study): incidence in the community and presenting to general practice.

OBJECTIVES: To estimate, overall and by organism, the incidence of infectious intestinal disease (IID) in the community, presenting to general practice (GP) and reported to national surveillance. DESIGN: Prospective, community cohort study and prospective study of GP presentation conducted between April 2008 and August 2009. SETTING: Eighty-eight GPs across the UK recruited from the Medical Research Council General Practice Research Framework and the Primary Care Research Networks. PARTICIPANTS: 6836 participants registered with the 88 participating practices in the community study; 991 patients with UK-acquired IID presenting to one of 37 practices taking part in the GP presentation study. MAIN OUTCOME MEASURES: IID rates in the community, presenting to GP and reported to national surveillance, overall and by organism; annual IID cases and GP consultations by organism. RESULTS: The overall rate of IID in the community was 274 cases per 1000 person-years (95% CI 254 to 296); the rate of GP consultations was 17.7 per 1000 person-years (95% CI 14.4 to 21.8). There were 147 community cases and 10 GP consultations for every case reported to national surveillance. Norovirus was the most common organism, with incidence rates of 47 community cases per 1000 person-years and 2.1 GP consultations per 1000 person-years. Campylobacter was the most common bacterial pathogen, with a rate of 9.3 cases per 1000 person-years in the community, and 1.3 GP consultations per 1000 person-years. We estimate that there are up to 17 million sporadic, community cases of IID and 1 million GP consultations annually in the UK. Of these, norovirus accounts for 3 million cases and 130,000 GP consultations, and Campylobacter is responsible for 500,000 cases and 80,000 GP consultations. CONCLUSIONS: IID poses a substantial community and healthcare burden in the UK. Control efforts must focus particularly on reducing the burden due to Campylobacter and enteric viruses.

Changes in serogroup and genotype prevalence among carried meningococci in the United Kingdom during vaccine implementation.

BACKGROUND: Herd immunity is important in the effectiveness of conjugate polysaccharide vaccines against encapsulated bacteria. A large multicenter study investigated the effect of meningococcal serogroup C conjugate vaccine introduction on the meningococcal population. METHODS: Carried meningococci in individuals aged 15-19 years attending education establishments were investigated before and for 2 years after vaccine introduction. Isolates were characterized by multilocus sequence typing, serogroup, and capsular region genotype and changes in phenotypes and genotypes assessed. RESULTS: A total of 8462 meningococci were isolated from 47 765 participants (17.7%). Serogroup prevalence was similar over the 3 years, except for decreases of 80% for serogroup C and 40% for serogroup 29E. Clonal complexes were associated with particular serogroups and their relative proportions fluctuated, with 12 statistically significant changes (6 up, 6 down). The reduction of ST-11 complex serogroup C meningococci was probably due to vaccine introduction. Reasons for a decrease in serogroup 29E ST-254 meningococci (from 1.8% to 0.7%) and an increase in serogroup B ST-213 complex meningococci (from 6.7% to 10.6%) were less clear. CONCLUSIONS: Natural fluctuations in carried meningococcal genotypes and phenotypes a can be affected by the use of conjugate vaccines, and not all of these changes are anticipatable in advance of vaccine introduction.

Evidence of person-to-person transmission of oseltamivir-resistant pandemic influenza A(H1N1) 2009 virus in a hematology unit.

We describe the first confirmed person-to-person transmission of oseltamivir-resistant pandemic influenza A(H1N1) 2009 virus that occurred in a hematology unit in the United Kingdom. Eleven cases of (H1N1) 2009 virus infection were identified, of which, ten were related as shown by sequence analysis of the hemagglutinin and neuraminidase genes. H275Y analysis demonstrated that 8 of 10 case patients had oseltamivir-resistant virus, with 4 of 8 case patients infected by direct transmission of resistant virus. Zanamivir should be considered as first-line therapy for influenza in patients with lymphopenic hematological conditions and uptake of influenza vaccination encouraged to further reduce the number of susceptible individuals.

Talking about colds and flu: the lay diagnosis of two common illnesses among older British people.

This paper reports on a study of the ways in which 54 older people in South Wales (UK) talk about the symptoms and causes of cold and influenza (flu). The study was designed to understand why older people might reject or accept the offer of seasonal flu vaccine, and in the course of the interviews respondents were also asked to express their views about the nature and causes of the two key illnesses. The latter are among the most common infections in human beings. In terms of the biomedical paradigm the common cold is caused by numerous respiratory viruses, whilst flu is caused by the influenza virus. Medical diagnosis is usually made on clinical grounds without laboratory confirmation. Symptoms of flu include sudden onset of fever and cough, and colds are characterized by sneezing, sore throat, and runny nose, but in practice the symptoms often overlap. In this study we examine the degree by which the views of lay people with respect to both diagnosis and epidemiology diverge with that which is evident in biomedical discourse. Our results indicate that whilst most of the identified symptoms are common to lay and professional people, the former integrate symptoms into a markedly different observational frame from the latter. And as far as causation is concerned it is clear that lay people emphasize the role of 'resistance' and 'immunity' at least as much as 'infection' in accounting for the onset of colds and flu. The data are analyzed using novel methods that focus on the co-occurrence of concepts and are displayed as semantic networks. As well as reporting on its findings the authors draw out some implications of the study for social scientific and policy discussions concerning lay diagnosis, lay expertise and the concept of an expert patient.

Methods for determining disease burden and calibrating national surveillance data in the United Kingdom: the second study of infectious intestinal disease in the community (IID2 study).

BACKGROUND: Infectious intestinal disease (IID), usually presenting as diarrhoea and vomiting, is frequently preventable. Though often mild and self-limiting, its commonness makes IID an important public health problem. In the mid 1990s around 1 in 5 people in England suffered from IID a year, costing around pound0.75 billion. No routine information source describes the UK's current community burden of IID. We present here the methods for a study to determine rates and aetiology of IID in the community, presenting to primary care and recorded in national surveillance statistics. We will also outline methods to determine whether or not incidence has declined since the mid-1990s. METHODS/DESIGN: The Second Study of Infectious Intestinal Disease in the Community (IID2 Study) comprises several separate but related studies. We use two methods to describe IID burden in the community - a retrospective telephone survey of self-reported illness and a prospective, all-age, population-based cohort study with weekly follow-up over a calendar year. Results from the two methods will be compared. To determine IID burden presenting to primary care we perform a prospective study of people presenting to their General Practitioner with symptoms of IID, in which we intervene in clinical and laboratory practice, and an audit of routine clinical and laboratory practice in primary care. We determine aetiology of IID using molecular methods for a wide range of gastrointestinal pathogens, in addition to conventional diagnostic microbiological techniques, and characterise isolates further through reference typing. Finally, we combine all our results to calibrate national surveillance data. DISCUSSION: Researchers disagree about the best method(s) to ascertain disease burden. Our study will allow an evaluation of methods to determine the community burden of IID by comparing the different approaches to estimate IID incidence in its linked components.

Risk factors for ciprofloxacin-resistant Campylobacter infection in Wales.

OBJECTIVES: To identify risk factors for ciprofloxacin resistance in both travel-related and domestically acquired Campylobacter infection. METHODS: Case-comparison study of patients with ciprofloxacin-resistant and ciprofloxacin-susceptible Campylobacter infection conducted in Wales during 2003 and 2004. RESULTS: Foreign travel was the major risk factor for ciprofloxacin-resistant infection [adjusted odds ratio (adjOR) 24.0, 95% confidence interval (95% CI) 12.6-45.9]. Among travellers, case patients were five times more likely to drink still bottled water (adjOR 4.7, 95% CI 1.0-21.7), whilst among non-travellers, case patients were three times more likely to drink sparkling bottled water (adjOR 3.3, 95% CI 1.5-7.4). There was no increased risk associated with eating poultry or prior quinolone use. CONCLUSIONS: Foreign travel remains the most important risk factor for ciprofloxacin-resistant Campylobacter infection. The possible association of both domestic- and travel-related ciprofloxacin-resistant Campylobacter infection with bottled water needs to be further explored.

Short-term and medium-term clinical outcomes of quinolone-resistant Campylobacter infection.

BACKGROUND: Campylobacter species is a leading cause of bacterial gastroenteritis worldwide. Quinolone resistance has emerged as an increasing problem among persons with Campylobacter infection over the past decade, but the clinical consequences are unclear. METHODS: A case-comparison study of patients infected with ciprofloxacin-resistant or ciprofloxacin-susceptible Campylobacter species was conducted in Wales during the period 2003-2004. Campylobacter isolates were classified as resistant or susceptible to ciprofloxacin on the basis of standardized disk diffusion methods. Participants were interviewed by telephone at the time of illness, 3 months later, and 6 months later to compare disease severity, duration of illness, and medium-term clinical outcomes. RESULTS: There was no difference between 145 persons with ciprofloxacin-resistant infection and 411 with ciprofloxacin-susceptible infection with regard to the severity or duration of acute illness. Mean duration of diarrhea was similar in patients with ciprofloxacin-resistant versus ciprofloxacin-susceptible infection (8.2 vs. 8.6 days; P = .57) and did not alter significantly after adjustment for potential covariates, including age, underlying disease, foreign travel, use of antidiarrheal medication, and use of antimicrobials in a multiple linear regression model. There was no difference between case patients and comparison patients in the frequency of reported symptoms or in general practitioner consultation rates at either the 3-month or the 6-month follow-up interview. CONCLUSIONS: In this study, there was no evidence of more-severe or prolonged illness in participants with quinolone-resistant Campylobacter infection, nor was there evidence of any adverse medium-term consequences. This suggests that the clinical significance of quinolone resistance in Campylobacter infection may have been overestimated.

Stemming the Tide of Antibiotic Resistance (STAR): a protocol for a trial of a complex intervention addressing the 'why' and 'how' of appropriate antibiotic prescribing in general practice.

BACKGROUND: After some years of a downward trend, antibiotic prescribing rates in the community have tended to level out in many countries. There is also wide variation in antibiotic prescribing between general practices, and between countries. There are still considerable further gains that could be made in reducing inappropriate antibiotic prescribing, but complex interventions are required. Studies to date have generally evaluated the effect of interventions on antibiotic prescribing in a single consultation and pragmatic evaluations that assess maintenance of new skills are rare. This paper describes the protocol for a pragmatic, randomized evaluation of a complex intervention aimed at reducing antibiotic prescribing by primary care clinicians. METHODS AND DESIGN: We developed a Social Learning Theory based, blended learning program (on-line learning, a practice based seminar, and context bound learning) called the STAR Educational Program. The 'why of change' is addressed by providing clinicians in general practice with information on antibiotic resistance in urine samples submitted by their practice and their antibiotic prescribing data, and facilitating a practice-based seminar on the implications of this data. The 'how of change' is addressed through context-bound communication skills training and information on antibiotic indication and choice. This intervention will be evaluated in a trial involving 60 general practices, with general practice as the unit of randomization (clinicians from each practice to either receive the STAR Educational Program or not) and analysis. The primary outcome will be the number of antibiotic items dispensed over one year. An economic and process evaluation will also be conducted. DISCUSSION: This trial will be the first to evaluate the effectiveness of this type of theory-based, blended learning intervention aimed at reducing antibiotic prescribing by primary care clinicians. Novel aspects include feedback of practice level data on antimicrobial resistance and prescribing, use of principles from motivational interviewing, training in enhanced communication skills that incorporates context-bound experience and reflection, and using antibiotic dispensing over one year (as opposed to antibiotic prescribing in a single consultation) as the main outcome. TRIAL REGISTRATION: Current Controlled Trials ISRCTN63355948.