The Gospel of Wealth and the National Health: The Rockefeller Foundation and Social Medicine in Britain's NHS, 1945-60.

This article examines the Rockefeller Foundation's (RF) engagement with the British National Health Service (NHS) between 1945 and 1960. It argues that the organization morally invested in the success of the NHS because, to them, it offered a world-inspiring model for how to provide medical care following the tenets of social medicine. The RF administratively and financially supported two health centers, in Edinburgh and Manchester, to help realize these ambitions. While the development of both centers exposed conflicting understandings of social medicine, these facilities later became important examples when British health centers expanded in number after the mid-1960s. The article also considers how the shift toward more communal forms of general practice provoked unease regarding privacy among patients. However, strategies used by medical professionals to offset these anxieties helped facilitate public acceptance of forms of care that aligned with the communitarian values of social democracy. The connections between American private philanthropy and British state planning show how a routine visit to the doctor in Edinburgh or Manchester in the 1950s was implicated in the broader politics of postwar global health.

Diabetic foot infection: Antibiotic therapy and good practice recommendations.

BACKGROUND: Healthcare events related to diabetic foot disease carry a burden of morbidity, mortality and economic cost. Prompt identification of clinical infection with appropriate tissue sampling limits use of broad spectrum empirical antibiotics and improves antibiotic stewardship. Staphylococcus aureus remains the commonest infecting organism and high-dose flucloxacillin remains the empirical antibiotic of choice for antibiotic naïve patients. Barriers to microbe-specific treatment include: adequate tissue sampling, delays in culture results, drug allergies and the emergence of multidrug-resistant organisms which can complicate the choice of targeted antibiotics. Even appropriate antibiotic treatment carries a risk of adverse events including the selection of resistant organisms. AIMS: Multidisciplinary clinical assessment of a diabetic foot infection is supported by the use of appropriate imaging modalities and deep tissue sampling, both of which are encouraged to enhance sampling accuracy. Narrow-spectrum, high dose, short duration antimicrobial therapy is ideal. Further clarity in these areas would be of benefit to clinicians involved in management of diabetic foot infections. METHODS: A combination of literature review with expert discussion was used to generate consensus on management of diabetic foot infection, with a specific focus on empirical antimicrobial therapy. RESULTS: Gram positive organisms represent the commonest pathogens in diabetic foot infection. However there are developing challenges in antimicrobial resistance and antibiotic availability. DISCUSSION: Recommendations for empirical therapy, including the choice of alternative oral agents and use of outpatient antibiotics would be of benefit to those involved in diabetic foot care. CONCLUSION: This paper provides advice on empirical antibiotic therapy that may be used as a framework for local guideline development to support clinicians in the management of diabetic foot infection.

Impact of COVID-19 pandemic on the utilization and quality of antibiotic use in the primary care setting in England, March 2019-March 2023: a segmented interrupted time series analysis of over 53 million individuals.

BACKGROUND: Amid the COVID-19 pandemic, we evaluated the short-term impact of COVID-19 on antibiotic use in primary care in England, focusing on both antibiotic quantity (overuse) and quality (misuse) of use. RESEARCH DESIGN AND METHODS: A population-based segmented interrupted analysis was applied on monthly dispensed antibiotics prescriptions using the Prescription Cost Analysis dataset (March/2019-March/2023). The quantity was assessed using number of items dispensed per 1000 inhabitants (NTI) and defined daily doses per 1000 inhabitants per day (DID), while quality was evaluated using WHO's Access Watch Reserve (AWaRe) classification, the proportion of '4C' antibiotics and the percentage of broad- to narrow-spectrum antibiotics. RESULTS: Findings indicate 8.6 (17.2%) and 0.4 (2.6%) increase in the NTI and DID, respectively, with a statistically significant uptick in trend noted after the second lockdown (ß5) for 'total antibiotics' for NTI only (ß5 = 1.6; 95% CI:0.17, 3.1). Quality assessment showed an increase in 'Access' antibiotics from 77% in March/2019 to 86% in March/2023; however, COVID-19 had no significant impact on WHO AWaRe classes. CONCLUSION: COVID-19's impact on antibiotic use quality and quantity appeared to be minimal, though an increase in utilization post-second lockdown coincided with healthcare system recovery. This suggests a nuanced impact of the pandemic, highlighting the importance of continued antimicrobial stewardship.

Impact of the COVID-19 pandemic on the utilisation and quality of antibiotic use in the Scottish primary care setting: a population-based segmented interrupted time-series analysis.

BACKGROUND: Inappropriate use of antibiotics is expected to increase during the COVID-19 pandemic, but there are limited data on COVID-19's long-term impact. We assessed the impact of COVID-19 on the quantity and quality of antibiotic use in Scotland. RESEARCH DESIGN AND METHODS: A segmented interrupted time series was applied to monthly dispensed antibiotics using prescription cost analysis data from March/2019 to March/2023. Antibiotic use was quantified using the number of items dispensed/1000 inhabitants (TIDs) and defined daily dose/1000 inhabitants/day (DIDs). The quality of antibiotic use was assessed using key quality indicators including the WHO AWaRe classification, proportion of broad-spectrum and "4C"-antibiotics. RESULTS: Overall, for all antibiotics, there was a non-significant increase in TIDs and DIDs before the first lockdown (March/2020) (ß1), but a decline in the level immediately after the first (ß2) and second lockdowns (ß4) (November/2020), albeit non-significant. However, a significant increase in the time trend after the second lockdown (ß5) for all antibiotic classes was observed. COVID-19 had no negative impact on AWaRe utilisation, with the proportion of all antibiotics from the Access group increasing from 76% in March/2019 to 90% in March/2023. The proportion of "4C" antibiotic reduced significantly after the second lockdown. CONCLUSIONS: Neither the utilisation nor the quality of total antibiotic use appeared to have been significantly affected by COVID-19.

Expert Opinion on Dose Regimen and Therapeutic Drug Monitoring for Long-Term Use of Dalbavancin: Expert Review Panel.

BACKGROUND: Dalbavancin is a lipoglycopeptide with a long elimination half-life and is currently licensed for the treatment of acute bacterial skin and skin structure infections in adults. Dalbavancin's potential in treating off-label complex Gram-positive infections is promising and real-world experience in treating such infections is growing. However, clear guidance on extended dosing regimens is lacking. OBJECTIVES: This study aimed to provide clear expert opinion based on recent pharmacokinetic literature and expert and real-world experience in infection areas that require > 2 weeks of treatment. METHODS: A single face-to-face meeting was held in September 2022 to collate expert opinion and present safety data of dalbavancin use in these clinical indications. A survey was completed by all authors on their individual experience with dalbavancin, which highlighted the heterogeneity in the regimens that were used. RESULTS: After review of the survey data and recent literature, this study presents expert panel proposals that accommodate different healthcare settings and resource availability, and centre around the length of treatment duration including up to or exceeding 6 weeks. To achieve adequate dalbavancin concentrations for up to 6 weeks, 3000 mg of dalbavancin should be given over 4 weeks for the agreed complex infections requiring > 2 weeks of treatment. Therapeutic drug monitoring (TDM) is advised for longer treatment durations and in cases of renal failure. Specific dosing recommendations for other special populations require further investigation. CONCLUSIONS: These proposals based on expert opinion have been defined to encourage best practice with dalbavancin, to optimise its administration beyond the current approved licenced dose across different healthcare settings.

A multicentre point prevalence study of antibiotics utilization in hospitalized patients in an urban secondary and a tertiary healthcare facilities in Nigeria: findings and implications.

OBJECTIVES: The understanding of antimicrobial utilization patterns is pertinent to successful implementation of the National Action Plans on Antimicrobial Resistance (AMR). There is, however, limited information on antibiotics utilization in Nigeria. This study was undertaken to build on existing information and provide direction for appropriate interventions including Antibiotics Stewardship Programs (ASP). METHOD: A Point Prevalence Study (PPS) was conducted in two public urban health facilities in Lagos, Nigeria using a design adapted from the European Center for Disease Prevention and Control (ECDC) and Global-PPS surveys. RESULTS: The prevalence of antibiotics use was 80.6% administered mostly parenterally (83.1% of total prescriptions) with concerns with extended surgical antibiotics prophylaxis. The mostly used antibiotics in the secondary hospital were parenteral metronidazole (32.4%), ceftriaxone (27.5%), and amoxicillin + clavulanate (8.2%) while the mostly used in the tertiary hospital were ceftriaxone (25.3%), parenteral metronidazole (19.1%), and amoxicillin + clavulanate (9.3%). There was an appreciable lack of specific functional capacities, policies, and processes to promote appropriate antimicrobial use in both hospitals. CONCLUSIONS: There is high rate of antibiotics utilization in these facilities with lack of institutional frameworks and processes for ensuring appropriate antibiotic use. The study provides the information needed to improve future antimicrobial use in hospitals and reduce AMR.

Meningococcal meningitis and COVID-19 co-infection.

Bacterial co-infection in the ongoing pandemic of COVID-19 is associated with poor outcomes but remains little understood. A 22-year-old woman presented with a 3-week history of fever, headache, neck stiffness, rigours and confusion. She was noted to have a purpuric rash over her hands and feet. Cerebrospinal fluid bacterial PCR was positive for Neisseria meningitidis A concurrent nasopharyngeal RT-PCR was positive for SARS-CoV-2, the causative virus of COVID-19. She was treated with antibiotics for bacterial meningitis and made a complete recovery. Bacterial infection from nasopharyngeal organisms has followed previous pandemic viral upper respiratory illnesses and the risk of bacterial co-infection in COVID-19 remains unclear. Research characterising COVID-19 should specify the frequency, species and outcome of bacterial co-infection. Management of bacterial co-infection in COVID-19 presents major challenges for antimicrobial stewardship and clinical management. Judicious use of local antibiotic guidelines and early liaison with infection specialists is key.

Wound botulism presenting as dysphagia to an ENT ward.

A 44-year-old man with a background of heroin injection drug use was referred to the ear, nose and throat team with a sore throat and dysphagia. He was treated with intravenous antibiotics and steroids for suspected uvulitis. He developed progressive bulbar weakness and symmetrical descending weakness of the upper extremities over a 12-hour period and was intubated prior to transfer to the intensive care unit.Botulinum heptavalent antitoxin was administered, and subsequent PCR assay confirmed Clostridium botulinum neurotoxin B from his most recent injection site. He was found unconscious on the ward 3 days following extubation. Postmortem confirmed he died from heroin intoxication.This case highlights the importance of considering wound botulism in injection drug users presenting with unexplained weakness, particularly of the lower cranial nerves. Botulism is not characteristically associated with signs of localised or systemic infection in contrary to other bacterial complications of injection drug use.

Duncan Tanner Essay Prize Winner 2014. Against the 'Sacred Cow': NHS Opposition and the Fellowship for Freedom in Medicine, 1948-72.

This essay recovers organized opposition to the National Health Service (NHS) by considering the Fellowship for Freedom in Medicine (FFM), a conservative organization of doctors who challenged the 'Sacred Cow' of nationalized healthcare in the 1950s and 1960s. While there has been little interest in anti-NHS politics because of shortcomings in the institution's historiography, this study suggests ways a new history of the service can be written. Central to that project is taking the broader ideological and emotive quality of the NHS seriously, and appreciating the way, for all sides of the political spectrum, as well as the general public, the service has always been a contested symbol of post-war British identity. This essay argues that two NHS 'crises'--panics over costs, and disillusionment within general practice--were not merely disagreements over budgets and pay-packets but politically charged moments infused with conservative anxieties over Britain's post-war trajectory. The FFM imagined the NHS as an economically dangerous bureaucratic machine that crushed medical independence and risked pushing the country towards dictatorship. Allies within the Conservative Party, private health insurance industry, and free-market 'think-tanks' worked with the FFM to challenge defences of both the service's operation and meaning. To appreciate why the NHS remains 'the closest thing the English have to a religion', one must consider the apostates as well as the faithful.

Oral versus intravenous antibiotic treatment for bone and joint infections (OVIVA): study protocol for a randomised controlled trial.

BACKGROUND: Bone and joint infection in adults arises most commonly as a complication of joint replacement surgery, fracture fixation and diabetic foot infection. The associated morbidity can be devastating to patients and costs the National Health Service an estimated £20,000 to £40,000 per patient. Current standard of care in most UK centres includes a prolonged course (4-6 weeks) of intravenous antibiotics supported, if available, by an outpatient parenteral antibiotic therapy service. Intravenous therapy carries with it substantial risks and inconvenience to patients, and the antibiotic-related costs are approximately ten times that of oral therapy. Despite this, there is no evidence to suggest that oral therapy results in inferior outcomes. We hypothesise that, by selecting oral agents with high bioavailability, good tissue penetration and activity against the known or likely pathogens, key outcomes in patients managed primarily with oral therapy are non-inferior to those in patients treated by intravenous therapy. METHODS: The OVIVA trial is a parallel group, randomised (1:1), un-blinded, non-inferiority trial conducted in thirty hospitals across the UK. Eligible participants are adults (>18 years) with a clinical syndrome consistent with a bone, joint or metalware-associated infection who have received ≤7 days of intravenous antibiotic therapy from the date of definitive surgery (or the start of planned curative therapy in patients treated without surgical intervention). Participants are randomised to receive either oral or intravenous antibiotics, selected by a specialist infection physician, for the first 6 weeks of therapy. The primary outcome measure is definite treatment failure within one year of randomisation, as assessed by a blinded endpoint committee, according to pre-defined microbiological, histological and clinical criteria. Enrolling 1,050 subjects will provide 90 % power to demonstrate non-inferiority, defined as less than 7.5 % absolute increase in treatment failure rate in patients randomised to oral therapy as compared to intravenous therapy (one-sided alpha of 0.05). DISCUSSION: If our results demonstrate non-inferiority of orally administered antibiotic therapy, this trial is likely to facilitate a dramatically improved patient experience and alleviate a substantial financial burden on healthcare services. TRIAL REGISTRATION: ISRCTN91566927 - 14/02/2013.

Bio-hazards and drug reactions: a cautionary tale.

Laboratory acquired infection with toxoplasmosis has been described. The clinical features in this situation can vary from asymptomatic to severe disease. Prophylactic therapy is recommended on the basis of clinical experience and case reports. We describe a case in a young man, where prophylaxis resulted in neutropenia complicated by subsequent Listeria meningitis.