Antibacterial resistance in ophthalmic infections: a multi-centre analysis across UK care settings.

BACKGROUND: Bacterial ophthalmic infections are common. Empirical treatment with topical broad-spectrum antibiotics is recommended for severe cases. Antimicrobial resistance (AMR) to agents used for bacterial ophthalmic infections make it increasingly important to consider changing resistance patterns when prescribing, however UK data in this area are lacking. We evaluate the epidemiology and antimicrobial susceptibilities of ophthalmic pathogens across care settings and compare these with local and national antimicrobial prescribing guidelines. METHODS: A retrospective, multi-centre observational analysis was undertaken of ophthalmic microbiology isolates between 2009 and 2015 at a centralised North-West London laboratory (incorporating data from primary care and five London teaching hospitals). Data were analysed using descriptive statistics with respect to patient demographics, pathogen distribution (across age-groups and care setting), seasonality, and susceptibility to topical chloramphenicol, moxifloxacin, and fusidic acid. RESULTS: Two thousand six hundred eighty-one isolates (n = 2168 patients) were identified. The commonest pathogen in adults was Staphylococcus spp. across primary, secondary, and tertiary care (51.7%; 43.4%; 33.6% respectively) and in children was Haemophilus spp. (34.6%;28.2%;36.6%). AMR was high and increased across care settings for chloramphenicol (11.8%;15.1%;33.8%); moxifloxacin (5.5%;7.6%;25.5%); and fusidic acid (49.6%;53.4%; 58.7%). Pseudomonas spp. was the commonest chloramphenicol-resistant pathogen across all care settings, whilst Haemophilus spp. was the commonest fusidic acid-resistant pathogen across primary and secondary care. More isolates were recorded in spring (31.6%) than any other season, mostly due to a significant rise in Haemophilus spp. CONCLUSIONS: We find UK national and local antimicrobial prescribing policies for ophthalmic infections may not be concordant with the organisms and antimicrobial susceptibilities found in clinical samples. We also find variations in microbial incidence related to patient age, clinical setting, and season. Such variations may have further important implications for prescribing practices and modification of antimicrobial guidelines.

Enhanced Recovery Protocols for Adults Undergoing Colorectal Surgery: A Systematic Review and Meta-analysis.

BACKGROUND: Enhanced surgical recovery protocols are designed to reduce hospital length of stay and health care costs. OBJECTIVE: This study aims to systematically review and summarize evidence from randomized and controlled clinical trials comparing enhanced recovery protocols versus usual care in adults undergoing elective colorectal surgery with emphasis on recent trials, protocol components, and subgroups for surgical approach and colorectal condition. DATA SOURCES: MEDLINE from 2011 to July 2017; reference lists of existing systematic reviews and included studies were reviewed to identify all eligible trials published before 2011. STUDY SELECTION: English language trials comparing a protocol of preadmission, preoperative, intraoperative, and postoperative components with usual care in adults undergoing elective colorectal surgery were selected. INTERVENTION: The enhanced recovery protocol for colorectal surgery was investigated. MAIN OUTCOME MEASURES: Length of stay, perioperative morbidity, mortality, readmission within 30 days, and surgical site infection were the primary outcomes measured. RESULTS: Twenty-five trials of open or laparoscopic surgery for cancer or noncancer conditions were included. Enhanced recovery protocols consisted of 4 to 18 components. Few studies fully described the various components. Length of stay (mean reduction, 2.6 days; 95% CI, -3.2 to -2.0) and risk of overall perioperative morbidity (risk ratio, 0.66; 95% CI, 0.54-0.80) were lower in enhanced recovery protocol groups than in usual care groups (moderate-quality evidence). All-cause mortality (rare), readmissions, and surgical site infection rates were similar between protocol groups (low-quality evidence). In predefined subgroup analyses, findings did not vary by surgical approach (open vs laparoscopic) or colorectal condition. LIMITATIONS: Protocols varied across studies and little information was provided regarding compliance with, or implementation of, specific protocol components. CONCLUSIONS: Enhanced recovery protocols for adults undergoing colorectal surgery improve patient outcomes with no increase in adverse events. Evidence was insufficient regarding which components, or component combinations, are key to improving patient outcomes. PROSPERO registration number: CRD42017067991.

Prospective assessment of a critical appraisal teaching programme on medical students' confidence and performance in appraising medical literature.

BACKGROUND: Previous research has demonstrated that medical students have insufficient knowledge of critical appraisal, a fundamental aspect of evidence-based medicine. We aimed to enhance medical students' critical appraisal skills using an innovative mixed-methods programme. METHODS: We designed a 2-day, mixed-methods, national teaching programme, including an interactive lecture and workshop, quiz and viva-style examination. Course efficacy was assessed using pre- and post-course confidence questionnaires and a quiz adapted from the validated Berlin Questionnaire. Data were analysed primarily using Wilcoxon Signed Ranks test. RESULTS: Fifty-nine participants from 17 medical schools completed the programme. Pre- and post-course scores demonstrated significant improvement in confidence (median score 5 vs 8; p < 0.001) and quiz performance (median score 9 vs 13; p < 0.001). CONCLUSION: Our study demonstrates the efficacy of a novel mixed-methods programme in teaching medical students about critical appraisal. Implementation of our approach within the undergraduate curriculum should enhance the uptake of these fundamental skills.