The first 5 years of Part 2A Orders: the use of powers from court applications to protect public health in England 2010-15.

BACKGROUND: Part 2A Orders are the legal means which allow local authorities (LAs), upon application to court, to exercise powers over persons, things or premises to protect public health. METHODS: We surveyed lead professionals involved in applications to understand the use and utility of such Orders since their inception in April 2010 to July 2015. RESULTS: All applications for Orders were granted; 29 for persons (28 for tuberculosis, 1 for HIV); these were renewed in 18 (18/25, 72%) cases up to seven times; 23 applications related to things (tattoo and piercing equipment); and three applications related to 'premises' (Escherichia coli 0137 on farm, faecal contamination). Use of the Orders against things occurred where there was failure of the Health and Safety Executive to transfer powers to LAs. Orders against persons were used as a last resort and renewed until treatment completion in the minority of cases (n = 3). One patient was detained under quarantine powers while assessing infectiousness. Significant difficulties in implementing the Part 2A Orders due to lack of resources, facilities and interagency collaboration were reported. CONCLUSIONS: Part 2A Orders are used as a last resort but improved facilities for safe and secure isolation would help improve implementation.

Adverse Effects and Choice between the Injectable Agents Amikacin and Capreomycin in Multidrug-Resistant Tuberculosis.

The prolonged use of injectable agents in a regimen for the treatment of multidrug-resistant tuberculosis (MDR-TB) is recommended by the World Health Organization, despite its association with ototoxicity and nephrotoxicity. We undertook this study to look at the relative adverse effects of capreomycin and amikacin. We reviewed the case notes of 100 consecutive patients treated at four MDR-TB treatment centers in the United Kingdom. The median total duration of treatment with an injectable agent was 178 days (interquartile range [IQR], 109 to 192 days; n = 73) for those with MDR-TB, 179 days (IQR, 104 to 192 days; n = 12) for those with MDR-TB plus fluoroquinolone resistance, and 558 days (IQR, 324 to 735 days; n = 8) for those with extensively drug-resistant tuberculosis (XDR-TB). Injectable use was longer for those started with capreomycin (183 days; IQR, 123 to 197 days) than those started with amikacin (119 days; IQR, 83 to 177 days) (P = 0.002). Excluding patients with XDR-TB, 51 of 85 (60%) patients were treated with an injectable for over 6 months and 12 of 85 (14%) were treated with an injectable for over 8 months. Forty percent of all patients discontinued the injectable due to hearing loss. Fifty-five percent of patients experienced ototoxicity, which was 5 times (hazard ratio [HR], 5.2; 95% confidence interval [CI], 1.2 to 22.6; P = 0.03) more likely to occur in those started on amikacin than in those treated with capreomycin only. Amikacin was associated with less hypokalemia than capreomycin (odds ratio, 0.28; 95% CI, 0.11 to 0.72), with 5 of 37 (14%) patients stopping capreomycin due to recurrent electrolyte loss. There was no difference in the number of patients experiencing a rise in the creatinine level of >1.5 times the baseline level. Hearing loss is frequent in this cohort, though its incidence is significantly lower in those starting capreomycin, which should be given greater consideration as a first-line agent.

Clinical use of whole genome sequencing for Mycobacterium tuberculosis.

Drug-resistant tuberculosis (TB) remains a major challenge to global health and to healthcare in the UK. In 2014, a total of 6,520 cases of TB were recorded in England, of which 1.4 % were multidrug-resistant TB (MDR-TB). Extensively drug-resistant TB (XDR-TB) occurs at a much lower rate, but the impact on the patient and hospital is severe. Current diagnostic methods such as drug susceptibility testing and targeted molecular tests are slow to return or examine only a limited number of target regions, respectively. Faster, more comprehensive diagnostics will enable earlier use of the most appropriate drug regimen, thus improving patient outcomes and reducing overall healthcare costs. Whole genome sequencing (WGS) has been shown to provide a rapid and comprehensive view of the genotype of the organism, and thus enable reliable prediction of the drug susceptibility phenotype within a clinically relevant timeframe. In addition, it provides the highest resolution when investigating transmission events in possible outbreak scenarios. However, robust software and database tools need to be developed for the full potential to be realized in this specialized area of medicine.

Clinical application of whole-genome sequencing to inform treatment for multidrug-resistant tuberculosis cases.

The treatment of drug-resistant tuberculosis cases is challenging, as drug options are limited, and the existing diagnostics are inadequate. Whole-genome sequencing (WGS) has been used in a clinical setting to investigate six cases of suspected extensively drug-resistant Mycobacterium tuberculosis (XDR-TB) encountered at a London teaching hospital between 2008 and 2014. Sixteen isolates from six suspected XDR-TB cases were sequenced; five cases were analyzed in a clinically relevant time frame, with one case sequenced retrospectively. WGS identified mutations in the M. tuberculosis genes associated with antibiotic resistance that are likely to be responsible for the phenotypic resistance. Thus, an evidence base was developed to inform the clinical decisions made around antibiotic treatment over prolonged periods. All strains in this study belonged to the East Asian (Beijing) lineage, and the strain relatedness was consistent with the expectations from the case histories, confirming one contact transmission event. We demonstrate that WGS data can be produced in a clinically relevant time scale some weeks before drug sensitivity testing (DST) data are available, and they actively help clinical decision-making through the assessment of whether an isolate (i) has a particular resistance mutation where there are absent or contradictory DST results, (ii) has no further resistance markers and therefore is unlikely to be XDR, or (iii) is identical to an isolate of known resistance (i.e., a likely transmission event). A small number of discrepancies between the genotypic predictions and phenotypic DST results are discussed in the wider context of the interpretation and reporting of WGS results.

Retention strategies and barriers for millennial nurses: a scoping review.

OBJECTIVE: The objectives of this scoping review were to explore the existing literature related to millennial nurse-retention strategies and barriers, to examine and conceptually map the evidence, to extract any differences between Generation Y and Generation Z nurses, and to identify any gaps in the literature. INTRODUCTION: The millennial generation has become the largest group of nurses in the workforce. As nursing leaders grow to understand this generation's tendency to change employers frequently, organizations need to identify and implement strategies and reduce barriers to retain this generation as employees. INCLUSION CRITERIA: Studies and reports including registered nurses born between 1980 and 2000 with any level of education preparation and in any setting or geographical location were included. Studies and reports that examined nurse-retention barriers and strategies were considered for inclusion. This review considered experimental and quasi-experimental study designs, analytical observational studies, case-control studies, analytical cross-sectional studies, descriptive observational studies, systematic reviews and meta-analyses, qualitative studies, and text and opinion papers. METHODS: The review was conducted in accordance with the JBI methodology for scoping reviews. Studies and reports written in English after 2010 were included. The databases searched included MEDLINE, CINAHL, Embase, Scopus, Ovid HealthStar, and PsycINFO. The search for unpublished studies and reports included MedNar and ProQuest Dissertations and Theses. Eligible studies and reports underwent data extraction by two independent reviewers using a tool created by the authors. Along with a narrative summary, results are presented in a diagrammatic format that aligns with the review objectives and questions. RESULTS: Thirty-eight publications were included in the review. Strategies for millennial nurse retention were provided in 21 publications, barriers were provided in two publications, and 15 publications provided both strategies and barriers. No publications provided information on the differences between Generation Y and Generation Z. The findings from this scoping review were grouped into five concepts, with strategies and barriers for millennial retention identified for each of the concepts. Concepts identified included leadership, work environment, professional growth, professional fatigue, and self-actualization. CONCLUSIONS: The current evidence base shows that barriers to and strategies for millennial nurse retention commonly focus on the work environment and the relationships between nursing leadership and the bedside nurse. A preliminary scan of the evidence indicates that creating a healthy work environment that is collaborative, fair, flexible, challenging, and provides opportunities for growth may keep millennial nurses engaged. Having nursing leadership that models these values and leads by example may help millennial nurses to feel safe and supported; however, due to the methodology employed in this review, further rigorous research is needed to confirm this.

Retention strategies and barriers for millennial nurses: a scoping review protocol.

OBJECTIVE: The objective of this scoping review is to explore the existing literature related to millennial nurse retention strategies and barriers; to examine and conceptually map the evidence; to extract any differences between nurse retention strategies and barriers for Generation Y and Generation Z; and to identify any gaps in the literature. INTRODUCTION: The millennial generation has become the largest group of nurses in the workforce and, as nursing leaders grow to understand their tendency to change employers frequently, it is important for organizations to identify and implement retention strategies and reduce retention barriers for this generation. INCLUSION CRITERIA: This review will consider studies that include registered nurses born between 1980 and 2000 with any level of educational preparation and in any setting or geographical location. The concept of this review is strategies and barriers for nurse retention. METHODS: The review will be conducted in accordance with JBI methodology for scoping reviews. Studies written in English and published after 2010 will be included. The databases to be searched include MEDLINE (PubMed), Embase (Elsevier), Scopus (Elsevier), Ovid Healthstar (Ovid), CINAHL (EBSCO), and PsycINFO (EBSCO). The search for unpublished studies will include MedNar (Mednar.com) and ProQuest Dissertations and Theses (ProQuest). Eligible studies will undergo data extraction by two independent reviewers using a tool created by the authors. Along with a narrative summary, results will be presented in diagrammatic or tabular form in a manner that aligns with the review objective and questions.

Antibiotic usage and stewardship in patients with COVID-19: too much antibiotic in uncharted waters?

BACKGROUND: Antimicrobial usage and stewardship programmes during COVID-19 have been poorly studied. Prescribing practice varies despite national guidelines, and there is concern that stewardship principles have suffered. AIM: To analyse antibiotic prescriptions during the COVID-19 pandemic at a teaching hospital and to propose improved approaches to stewardship. METHODS: We reviewed COVID-19 admissions to medical wards and intensive care units (ICUs) in a London teaching hospital to assess initial antibiotic usage and evidence of bacterial co-infection, and to determine if our current antibiotic guidelines were adhered to. FINDINGS: Data from 130 inpatients (76% medical and 24% ICU) were obtained. On admission, 90% were treated with antibiotics. No microbiological samples taken on admission provided definitive evidence of respiratory co-infection. In 13% of cases, antibiotics were escalated, usually without supporting clinical, radiological or laboratory evidence. In 16% of cases, antibiotics were stopped or de-escalated within 72 h. Blood results and chest radiographs were characteristic of COVID-19 in 20% of ward patients and 42% of ICU patients. Overall mortality was 25% at 14 days - similar to rates described for the UK as a whole. CONCLUSION: The majority of patients received antibiotics despite limited evidence of co-infection. Most patients received narrower spectrum antibiotics than recommended by NICE. As understanding of the natural history of COVID-19 infections progresses, stewardship programmes will need to evolve; however, at this point, we feel that a more restrictive antibiotic prescribing approach is warranted. We propose strategies for effective stewardship and estimate the effect this may have on antibiotic consumption.

A cost comparison of amikacin therapy with bedaquiline, for drug-resistant tuberculosis in the UK.

OBJECTIVES: Prioritisation of oral bedaquiline over the injectable agents in the treatment of multidrug-resistant Tuberculosis (MDR-TB) in the World Health Organisations (WHO) 2019 guidelines prompted this UK analysis of cost implications. The objective was to estimate the costs of amikacin versus bedaquiline in MDR TB treatment regimens using a historical cohort where the injectable agents were the standard of care. METHODS: This was a retrospective study using a known cohort of UK patients treated with an injectable agent, with data available on resource use, costs for the use of amikacin were compared with those for bedaquiline, based on recommended monitoring for bedaquiline. RESULTS: The estimated cost of treatment per patient had mean (sd) of £27,236 (4952) for the observed injectable group, £30,264 (3392) and 36,309 (3901) for the 6 and 8 month amikacin groups, and £31,760 (2092) for the bedaquiline group. The cost in the bedaquiline group was £30,772 (1855) with a 10% reduction and £27,079 (1234) with a 33% reduction in-patient stay. CONCLUSIONS: In most scenarios, bedaquiline is close to cost neutral compared with injectable therapy, especially if, as expected, some reduction in duration of admission is possible as a result of bedaquiline's more rapid culture conversion.

Associations among the food environment, diet quality and weight status in Cree children in Québec.

OBJECTIVE: To explore the relationship among children's diet quality, weight status and food environment in subarctic Canada. DESIGN: In the cross-sectional study, children's BMI was calculated, diet quality was assessed using three 24 h dietary recalls and children were asked about their home food environment and source of meals. SETTING: Two Aboriginal Cree communities in northern Québec. SUBJECTS: Two hundred and one children in grades 4-6. RESULTS: The majority (64.2%) of children were overweight (29.9%) or obese (34.3%). Weight status was not associated with reported restaurant meal frequency or the home food environment. The 18% of children who consumed three or more restaurant meals in the three days of recall consumed, on average, 2004 kJ (479 kcal) more energy daily than children consuming no restaurant meals and had higher intakes of fat, saturated fat, Ca and soda. Most foods contributing to energy and dietary fat were energy-dense market foods of low nutritional value such as sweetened beverages and snack foods. Only 68% of children reported often having fruits and vegetables in the home and 98.5% of children consumed less than 5 fruits and vegetables daily. Many children (42.8%) were at risk of Zn inadequacy. Only 19% of children consumed 2 or more servings of milk daily, and the mean intakes of Ca and vitamin D were below the recommended adequate intake. Traditional game meat was consumed infrequently, but contributed significantly to Fe and Zn intake. CONCLUSIONS: Childhood obesity in subarctic communities prevailed in a food environment typified by high-energy-density commercial foods of low nutritional value.

Drug resistant TB: UK multicentre study (DRUMS): Treatment, management and outcomes in London and West Midlands 2008-2014.

OBJECTIVES: Detailed information regarding treatment practices and outcomes of MDR-TB treatment in the UK is required as a baseline for care improvements. METHODS: 100 consecutive cases between 2008 and 2014 were reviewed retrospectively at 4 MDR-TB treatment centres in England to obtain information on drug treatment choices, hospital admission duration and outcomes for MDR-TB. RESULTS: Initial hospital admission was long, median 62.5 (IQR 20-106, n = 92) days, and 13% (12/92) of patients lost their home during this period. Prolonged admission was associated with pulmonary cases, cavities on chest radiograph, a public health policy of waiting for sputum culture conversion (CC) and loss of the patient's home. Sputum CC occurred at a median of 33.5 (IQR 16-55, n = 46) days. Treatment success was high (74%, 74/100) and mortality low (1%, 1/100). A significant proportion of the cohort had "neutral" results due to deportation and transfer overseas (12%, (12/100)). 14% (14/100) had negative outcomes for which poor adherence was the main reason (62%, 9/14). CONCLUSIONS: Successful outcome is common in recognised centres and limited by adherence rather than microbiological failure. Duration of hospital admission is influenced by lack of suitable housing and some variation in public health practice. Wider access to long-term assisted living facilities could improve completion rates.

XDR-TB transmission in London: Case management and contact tracing investigation assisted by early whole genome sequencing.

OBJECTIVES: We describe the first published cluster of extensively drug resistant Tuberculosis (XDR-TB) in the UK and show how early whole genome sequencing (WGS) of Mtb can assist in case management and contact investigations. METHODS: We describe the contact tracing investigation undertaken after the presentation of an adult with XDR-TB. Active cases were treated with an XDR-TB drug regimen and contacts underwent a programme of follow-up for 2 years. All isolates of Mycobacterium tuberculosis (Mtb) were assessed early using whole genome sequencing (WGS) as well as routine drug susceptibility testing (DST). RESULTS: Thirty-three contacts were screened. In the first year one confirmed and one probable case were identified through contact tracing. A further possible case was identified through epidemiological links. Two confirmed cases were identified through WGS 2 years later. Twenty-five (80%) contacts without evidence of tuberculosis were adherent to 1 year of follow-up and 14 (45%) were adherent to 2 years of follow-up. WGS of Mtb was used to guide drug choices, rapidly identify transmission events, and alter public health management. CONCLUSION: WGS of Mtb enabled rapid effective individualized treatment and facilitated public health interventions by early identification of transmission events.