A standardized methodology for the surveillance of antimicrobial prescribing linked to clinical indications in primary care.

Background: A key component of strategies to reduce antimicrobial resistance is better antimicrobial prescribing. The majority of antibiotics are prescribed in primary care. While many existing surveillance systems can monitor trends in the quantities of antibiotics prescribed in this setting, it can be difficult to monitor the quality of prescribing as data on the condition for which prescriptions are issued are often not available. We devised a standardized methodology to facilitate the monitoring of condition-specific antibiotic prescribing in primary care. Methods: We used a large computerized general practitioner database to develop a standardized methodology for routine monitoring of antimicrobial prescribing linked to clinical indications in primary care in the UK. Outputs included prescribing rate by syndrome and percentages of consultations with antibiotic prescription, for recommended antibiotic, and of recommended treatment length. Results: The standardized methodology can monitor trends in proportions of common infections for which antibiotics were prescribed, the specific drugs prescribed and duration of treatment. These data can be used to help assess the appropriateness of antibiotic prescribing and to assess the impact of prescribing guidelines. Conclusions: We present a standardized methodology that could be applied to any suitable national or local database and adapted for use in other countries.

Whole genome sequencing reveals an outbreak of Salmonella Enteritidis associated with reptile feeder mice in the United Kingdom, 2012-2015.

Analysis of whole genome sequencing data uncovered a previously undetected outbreak of Salmonella Enteritidis that had been on-going for four years. Cases were resident in all countries of the United Kingdom and 40% of the cases were aged less than 11 years old. Initial investigations revealed that 30% of cases reported exposure to pet snakes. A case-control study was designed to test the hypothesis that exposure to reptiles or their feed were risk factors. A robust case-definition, based on the single nucleotide polymorphism (SNP) profile, increased the power of the analytical study. Following univariable and multivariable analysis, exposure to snakes was the only variable independently associated with infection (Odds ratio 810 95% CI (85-7715) p < 0.001). Isolates of S. Enteritidis belonging to the outbreak profile were recovered from reptile feeder mice sampled at the retail and wholesale level. Control measures included improved public health messaging at point of sale, press releases and engagement with public health and veterinary counterparts across Europe. Mice destined to be fed to reptiles are not regarded as pet food and are not routinely tested for pathogenic bacteria. Routine microbiological testing to ensure feeder mice are free from Salmonella is recommended.

Cyclospora infection linked to travel to Mexico, June to September 2015.

Cyclospora cayetanensis was identified in 176 returned travellers from the Riviera Maya region of Mexico between 1 June and 22 September 2015; 79 in the United Kingdom (UK) and 97 in Canada. UK cases completed a food exposure questionnaire. This increase in reported Cyclospora cases highlights risks of gastrointestinal infections through travelling, limitations in Cyclospora surveillance and the need for improved hygiene in the production of food consumed in holiday resorts.

Trends in antibiotic prescribing in primary care for clinical syndromes subject to national recommendations to reduce antibiotic resistance, UK 1995-2011: analysis of a large database of primary care consultations.

OBJECTIVES: To measure trends in antibiotic prescribing in UK primary care in relation to nationally recommended best practice. PATIENTS AND METHODS: A descriptive study linking individual patient data on diagnosis and prescription in a large primary care database, covering 537 UK general practices during 1995-2011. RESULTS: The proportion of cough/cold episodes for which antibiotics were prescribed decreased from 47% in 1995 to 36% in 1999, before increasing to 51% in 2011. There was marked variation by primary care practice in 2011 [10th-90th percentile range (TNPR) 32%-65%]. Antibiotic prescribing for sore throats fell from 77% in 1995 to 62% in 1999 and then stayed broadly stable (TNPR 45%-78%). Where antibiotics were prescribed for sore throat, recommended antibiotics were used in 69% of cases in 2011 (64% in 1995). The use of recommended short-course trimethoprim for urinary tract infection (UTI) in women aged 16-74 years increased from 8% in 1995 to 50% in 2011; however, a quarter of practices prescribed short courses in ≤16% of episodes in 2011. For otitis media, 85% of prescriptions were for recommended antibiotics in 2011, increasing from 77% in 1995. All these changes in annual prescribing were highly statistically significant (P < 0.001). CONCLUSIONS: The implementation of national guidelines in UK primary care has had mixed success, with prescribing for coughs/colds, both in total and as a proportion of consultations, now being greater than before recommendations were made to reduce it. Extensive variation by practice suggests that there is significant scope to improve prescribing, particularly for coughs/colds and for UTIs.

Multiple outbreaks of Salmonella braenderup associated with consumption of iceberg lettuce.

The aim of this study was to describe the findings from an outbreak investigation following several apparently unrelated community outbreaks of gastroenteritis. Epidemiological, environmental, laboratory and traceback investigations were used to identify the source of the outbreak. We enrolled 23 (of 29) laboratory confirmed cases and 24 neighbourhood case-nominated controls in a case-control study which revealed that illness was associated with consumption of iceberg lettuce (matched odds ratio 8.0 (95% CI 1.1-355) contaminated with Salmonella braenderup. Several eating establishments were affected and the lettuce was traced back to a single producer in Spain. This is the first UK report implicating S. braenderup in an outbreak due to lettuce. The results highlight the need to increase attention to the various stages in the farm-to-fork process to reduce produce-associated outbreaks related to the global food trade.

Social patterning of telephone health-advice for diarrhoea and vomiting: analysis of 24 million telehealth calls in England.

OBJECTIVES: Gastrointestinal (GI) infections are common and most people do not see a physician. There is conflicting evidence of the impact of socioeconomic status (SES) on risk of GI infections. We assessed the relationship between SES and GI calls to two National Health Service (NHS) telephone advice services in England. METHODS: Over 24 million calls to NHS Direct (2010-13) and NHS 111 (2013-15) were extracted from Public Health England (PHE) syndromic surveillance systems. The relationship between SES and GI calls was assessed using generalised linear models (GLM). RESULTS: Adjusting for rurality and age-sex interactions, in NHS Direct, children in disadvantaged areas were at lower risk of GI calls; in NHS 111 there was a higher risk of GI calls in disadvantaged areas for all ages (0-4 years RR 1.27, 95% CI 1.25-1.29; 5-9 years RR 1.43, 95% CI 1.36-1.51; 10-14 years RR 1.36, 95% CI 1.26-1.41; 15-19 years RR 1.59, 95% CI 1.52-1.67; 20-59 years RR 1.50, 95% CI 1.47-1.53, 60 years and over RR 1.12, 95% CI 1.09-1.14). CONCLUSIONS: Disadvantaged areas had higher risk of GI calls in NHS 111. This may relate to differences in exposure or vulnerability to GI infections, or propensity to call about GI infections.

Effect of social factors on winter hospital admission for respiratory disease: a case-control study of older people in the UK.

BACKGROUND: Every winter, hospitals in the UK and other developed countries experience a surge in respiratory admissions. Ecological studies suggest that social circumstances may be an important determinant. AIM: To establish the most important factors associated with winter hospital admissions among older people presenting with acute respiratory disease, especially the relative effect of social factors. DESIGN OF STUDY: case-control study. SETTING: Seventy-nine general practices in central England. METHOD: Of a cohort of patients consulting medical services with lower respiratory tract infection or exacerbation of chronic respiratory disease, 157 hospitalised cases were compared to 639 controls. Social, medical, and other factors were examined by interview and GP records. RESULTS: Measures of material deprivation were not significant risk factors for admission at either individual or area level, although social isolation (odds ratio [OR] 4.5; 95% confidence interval [CI] = 1.3 to 15.8) resulted in an increased risk of admission. The most important independent risk factor was the presence of chronic obstructive pulmonary disease (COPD; OR 4.0; 95% CI = 1.4 to 11.4), other chronic disease (OR 2.9; 95% CI = 1.2 to 7.0), or both (OR 6.7; 95% CI = 2.4 to 18.4). Being housebound was also an independent risk factor (OR 2.2; 95% CI = 1.0 to 4.8). CONCLUSION: Socioeconomic factors had little relative effect compared with medical and functional factors. The most important was the presence of long-term medical conditions (especially COPD), being housebound, and having received two or more courses of oral steroid treatment in the previous year. This combination of factors could be used by primary medical services to identify older patients most vulnerable to winter admissions. Clinicians should ensure that patients with COPD are better supported to manage their condition.

Age, sex, material deprivation and respiratory mortality.

The aim of this study was to examine the effects of age, sex and social deprivation on mortality rates for respiratory infection. An ecological study was undertaken, using official public health mortality data and population census data for the West Midlands health region, UK. Postcodes at the time of death were used to assign Townsend deprivation scores and the resulting deprivation quintile. Poisson regression analysis was used to estimate the association between respiratory mortality, deprivation quintile, age and sex. In most age groups there was a statistically significant trend of increasing mortality with increasing deprivation. The relative risk for the most deprived was highest in the 45-64 year age-group (RR=4.4, 95% CI 4.0, 4.8). However, the absolute risks were greater in those aged 75-84 years (RR=1.3, 95% CI 1.3, 1.4) where the annual death rate was 669 per 100,000. Consistently higher mortality rates were seen in males. These results suggest that the risk of mortality from respiratory infection varies by sex and generally increases with increasing age and deprivation quintile. The identified association between deprivation and mortality from respiratory infections is consistent with the effect of deprivation on many other diseases. Addressing the social determinants of ill health may help to reduce the high burden of respiratory mortality in the UK. However, individual level studies and examination of other areas are needed to explain the mechanisms by which deprivation increases the risk of mortality from respiratory infection, and thereby identify target groups for effective interventions.

Social deprivation and hospital admission for respiratory infection: an ecological study.

STUDY OBJECTIVE: To examine the relationship between social deprivation and risk of hospital admission for respiratory infection. METHODS AND SUBJECTS: Ecological study using hospital episode statistics and population census data. Cases were residents of the West Midlands Health Region admitted to hospital with a diagnosis of respiratory infection, acute respiratory infection, pneumonia or influenza over a 5-year period. Postcodes of cases were used to assign Townsend deprivation scores; these were then ranked and divided into five deprivation categories. Poisson regression analysis was used to estimate the magnitude of effect for associations between deprivation category and hospital admission by age and admitting diagnosis. MAIN RESULTS: There were 136755 admissions for respiratory infection, equivalent to an annual admission rate of 27.1 per 1000 population (95% CI = 26.9-27.2). Deprivation was associated with increased admission rates for all respiratory infection (P < 0.0001) and affected all age-groups. The greatest effect was in the 0-4 years age-group with admission rates 91% higher in the most deprived children compared to the least deprived. Hospital admissions for acute respiratory infection and pneumonia were both significantly associated with deprivation (P < 0.0001). CONCLUSIONS: Respiratory infection is associated with social inequalities in all age-groups, particularly in children. Prevention of respiratory infection could make an important contribution to reducing health inequalities.

Widening inequalities in MMR vaccine uptake rates among ethnic groups in an urban area of the UK during a period of vaccine controversy (1994-2000).

We examined MMR vaccine uptake among ethnic groups in Birmingham, UK between 1994 and 2000, a period incorporating adverse MMR vaccine publicity. From 1994 to 2000 overall uptake: (1) fell significantly from 91.1% in 1994 to 89.8% (chi(2) for trend p<0.001) in 2000, (2) in Asian children significantly increased (chi(2) for trend p<0.001), and (3) in White children significantly decreased (chi(2) for trend p<0.001). Differences between ethnic groups with the highest (Asian) and the lowest (Black Caribbean) uptake rates increased from 2.1% in 1994 (p=ns) to 6.8% in 2000 (p<0.001). This study suggests underlying ethnic inequalities in MMR vaccine uptake and differential response to adverse vaccine publicity.

Material deprivation, hospitalisation and adverse events temporally associated with immunisation.

We examined hospital admissions for illness temporally associated with childhood immunisations to determine the influence of material deprivation. Children aged <5 years hospitalised in the West Midlands were identified using ICD10 codes (Y580-Y599) from April 1995 through March 2000. Material deprivation was measured using the Townsend score. Children from deprived areas were at increased risk (OR = 4.49, 95% CI 3.14-7.78) compared to children from affluent areas and, were more likely to be admitted following immunisation with pertussis vaccine (OR = 5.91, 95% CI 2.69-12.29). Further research is required to determine the contribution of healthcare providers and parents to this health differential.

Invasive Haemophilus influenzae disease: an ecological study of sociodemographic risk factors before and after the introduction of Hib conjugate vaccine.

This study examines the impact of H. influenzae type b (Hib) conjugate vaccine on sociodemographic risk factors for invasive H. influenzae disease in the 2 years before and immediately after the introduction of Hib conjugate vaccine. An ecological study design was used and cases were identified using active surveillance employing several surveillance systems. The study population comprised all children aged < 5 years resident in the West Midlands, an English health region, with laboratory confirmed invasive disease 2 years before (1990-1992) and 2 years after (1992-1994) the introduction of Hib conjugate vaccine. Selected sociodemographic variables derived from the UK census were obtained for all census enumeration districts in the region. Each variable was then ranked and divided into six categories. Linear associations between disease rates and sociodemographic variables were examined. Overall, there was a significant reduction in the incidence of invasive H. influenzae disease. In the pre-conjugate vaccine era there were trends of decreasing disease incidence with increasing child population density (p = 0.012) and total population density (p = 0.0023). In the post-conjugate vaccine period, total population density (p = 0.0275) remained significant and a trend of increasing disease incidence with increasing population mobility (p = 0.0012) was seen. Although Hib conjugate vaccine has resulted in a dramatic reduction in disease incidence changes in sociodemographic risk factors were identified in the post-conjugate vaccine period, particularly population mobility. Our results may have implications for current and future vaccine strategies.