N-of-1 Trials of Antimicrobial Stewardship Interventions to Optimize Antibiotic Prescribing for Upper Respiratory Tract Infection in Emergency Departments: Protocol for a Quasi-Experimental Study.

BACKGROUND: Antimicrobial stewardship programs attempting to optimize antibiotic therapy and clinical outcomes mainly focus on inpatient and outpatient settings. The lack of antimicrobial stewardship program studies in the emergency department (ED) represents a gap in tackling the problem of antimicrobial resistance as EDs treat a substantial number of upper respiratory tract infection cases throughout the year. OBJECTIVE: We intend to implement two evidence-based interventions: (1) patient education and (2) providing physician feedback on their prescribing rates. We will incorporate evidence from a literature review and contextualizing the interventions based on findings from a local qualitative study. METHODS: Our study uses a quasi-experimental design to evaluate the effects of interventions over time in the EDs of 4 public hospitals in Singapore. We will include an initial control period of 18 months. In the next 6 months, we will randomize 2 EDs to receive 1 intervention (ie, patient education) and the other 2 EDs to receive the alternative intervention (ie, physician feedback). All EDs will receive the second intervention in the subsequent 6 months on top of the ongoing intervention. Data will be collected for another 6 months to assess the persistence of the intervention effects. The information leaflets will be handed to patients at the EDs before they consult with the physician, while feedback to individual physicians by senior doctors is in the form of electronic text messages. The feedback will contain the physicians' antibiotic prescribing rate compared with the departments' overall antibiotic prescribing rate and a bite-size message on good antibiotic prescribing practices. RESULTS: We will analyze the data using segmented regression with difference-in-difference estimation to account for concurrent cluster comparisons. CONCLUSIONS: Our proposed study assesses the effectiveness of evidence-based, context-specific interventions to optimize antibiotic prescribing in EDs. These interventions are aligned with Singapore's national effort to tackle antimicrobial resistance and can be scaled up if successful. TRIAL REGISTRATION: ClinicalTrials.gov NCT05451863; https://clinicaltrials.gov/study/NCT05451836. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/50417.

Applying Andersen's healthcare utilization model to assess factors influencing patients' expectations for diagnostic tests at emergency department visits during the COVID-19 pandemic.

Background: The uncertainties surrounding the COVID-19 pandemic led to a surge in non-urgent emergency department (ED) attendance among people presenting with upper respiratory tract infection (URTI) symptoms. These non-urgent visits, often manageable in primary care, exacerbated ED overcrowding, which could compromise the quality of ED services. Understanding patients' expectations and the reasons for these ED visits is imperative to mitigate the problem of ED overcrowding. Hence, we assessed the factors influencing patients' expectations for diagnostic tests during their ED visits for uncomplicated URTI during different phases of the pandemic. Methods: We conducted a cross-sectional study on adults with URTI symptoms seeking care at four public EDs in Singapore between March 2021 and March 2022. We segmented the study period into three COVID-19 pandemic phases-containment, transition, and mitigation. The outcome variables are whether patients expected (1) a COVID-19-specific diagnostic test, (2) a non-COVID-19-specific diagnostic test, (3) both COVID-19-specific and non-COVID-19-specific diagnostic tests, or (4) no diagnostic test. We built a multinomial regression model with backward stepwise selection and classified the findings according to Andersen's healthcare utilization model. Results: The mean age of participants was 34.5 (12.7) years. Factors (adjusted odds ratio [95% confidence interval]) influencing expectations for a COVID-19-specific diagnostic test in the ED include younger age {21-40 years: (2.98 [1.04-8.55])}, no prior clinical consultation (2.10 [1.13-3.89]), adherence to employer's health policy (3.70 [1.79-7.67]), perceived non-severity of illness (2.50 [1.39-4.55]), being worried about contracting COVID-19 (2.29 [1.11-4.69]), and during the transition phase of the pandemic (2.29 [1.15-4.56]). Being non-employed influenced the expectation for non-COVID-19-specific diagnostic tests (3.83 [1.26-11.66]). Factors influencing expectations for both COVID-19-specific and non-COVID-19-specific tests include younger age {21-40 years: (3.61 [1.26-10.38]); 41-60 years: (4.49 [1.43-14.13])}, adherence to employer's health policy (2.94 [1.41-6.14]), being worried about contracting COVID-19 (2.95 [1.45- 5.99]), and during the transition (2.03 [1.02-4.06]) and mitigation (2.02 [1.03-3.97]) phases of the pandemic. Conclusion: Patients' expectations for diagnostic tests during ED visits for uncomplicated URTI were dynamic across the COVID-19 pandemic phases. Expectations for COVID-19-specific diagnostic tests for ED visits for uncomplicated URTI were higher among younger individuals and those worried about contracting COVID-19 during the COVID-19 pandemic. Future studies are required to enhance public communications on the availability of diagnostic services in primary care and public education on self-management of emerging infectious diseases such as COVID-19.

A multi-institutional exploration of emergency medicine physicians' attitudes and behaviours on antibiotic use during the COVID-19 pandemic: a mixed-methods study.

BACKGROUND: The COVID-19 pandemic has changed the epidemiology of upper respiratory tract infections (URTI) and the disease profile of patients attending the emergency department (ED). Hence, we sought to explore the changes in ED physicians' attitudes and behaviours in four EDs in Singapore. METHODS: We employed a sequential mixed-methods approach (quantitative survey followed by in-depth interviews). Principal component analysis was performed to derive latent factors, followed by multivariable logistic regression to explore the independent factors associated with high antibiotic prescribing. Interviews were analysed using the deductive-inductive-deductive framework. We derive five meta-inferences by integrating the quantitative and qualitative findings with an explanatory bidirectional framework. RESULTS: We obtained 560 (65.9%) valid responses from the survey and interviewed 50 physicians from various work experiences. ED physicians were twice as likely to report high antibiotic prescribing rates pre-COVID-19 pandemic than during the pandemic (AOR = 2.12, 95% CI 1.32 to 3.41, p = 0.002). Five meta-inferences were made by integrating the data: (1) Less pressure to prescribe antibiotics due to reduced patient demand and more patient education opportunities; (2) A higher proportion of ED physicians self-reported lower antibiotic prescribing rates during the COVID-19 pandemic but their perception of the overall outlook on antibiotic prescribing rates varied; (3) Physicians who were high antibiotic prescribers during the COVID-19 pandemic made less effort for prudent antibiotic prescribing as they were less concerned about antimicrobial resistance; (4) the COVID-19 pandemic did not change the factors that lowered the threshold for antibiotic prescribing; (5) the COVID-19 pandemic did not change the perception that the public's knowledge of antibiotics is poor. CONCLUSIONS: Self-reported antibiotic prescribing rates decreased in the ED during the COVID-19 pandemic due to less pressure to prescribe antibiotics. The lessons and experiences learnt from the COVID-19 pandemic can be incorporated into public and medical education in the war against antimicrobial resistance going forward. Antibiotic use should also be monitored post-pandemic to assess if the changes are sustained.

Antibiotic expectation, behaviour, and receipt among patients presenting to emergency departments with uncomplicated upper respiratory tract infection during the COVID-19 pandemic.

OBJECTIVES: Pre-COVID-19 pandemic, patients who attended the emergency department (ED) for upper respiratory tract infection (URTI) were more likely to receive antibiotics if they expected them. These expectations could have changed with the change in health-seeking behaviour during the pandemic. We assessed the factors associated with antibiotics expectation and receipt for uncomplicated URTI patients in four Singapore EDs during the COVID-19 pandemic. METHODS: We conducted a cross-sectional study on adult patients with URTI from March 2021 to March 2022 in four Singapore EDs and assessed the determinants of antibiotics expectation and receipt using multivariable logistic regression models. We also assessed the reasons patients expect antibiotics during their ED visit. RESULTS: Among 681 patients, 31.0% expected antibiotics while 8.7% received antibiotics during their ED visit. Factors (adjusted odds ratio [95% confidence interval]) that significantly influenced expectation for antibiotics include: 1) prior consultation for current illness with (6.56 [3.30-13.11]) or without (1.50 [1.01-2.23]) antibiotics prescribed; 2) anticipation for COVID-19 test (1.56 [1.01-2.41]); and 3) poor (2.16 [1.26-3.68]) to moderate (2.26 [1.33-3.84]) knowledge on antibiotics use and resistance. Patients expecting antibiotics were 10.6 times (10.64 [5.34-21.17]) more likely to receive antibiotics. Those with tertiary education were twice (2.20 [1.09-4.43]) as likely to receive antibiotics. CONCLUSION: In conclusion, patients with URTI who expected antibiotics to be prescribed remained more likely to receive it during the COVID-19 pandemic. This highlights the need for more public education on the non-necessity for antibiotics for URTI and COVID-19 to address the problem of antibiotic resistance.

Detection of hospital environmental contamination during SARS-CoV-2 Omicron predominance using a highly sensitive air sampling device.

Background and objectives: The high transmissibility of SARS-CoV-2 has exposed weaknesses in our infection control and detection measures, particularly in healthcare settings. Aerial sampling has evolved from passive impact filters to active sampling using negative pressure to expose culture substrate for virus detection. We evaluated the effectiveness of an active air sampling device as a potential surveillance system in detecting hospital pathogens, for augmenting containment measures to prevent nosocomial transmission, using SARS-CoV-2 as a surrogate. Methods: We conducted air sampling in a hospital environment using the AerosolSenseTM air sampling device and compared it with surface swabs for their capacity to detect SARS-CoV-2. Results: When combined with RT-qPCR detection, we found the device provided consistent SARS-CoV-2 detection, compared to surface sampling, in as little as 2 h of sampling time. The device also showed that it can identify minute quantities of SARS-CoV-2 in designated "clean areas" and through a N95 mask, indicating good surveillance capacity and sensitivity of the device in hospital settings. Conclusion: Active air sampling was shown to be a sensitive surveillance system in healthcare settings. Findings from this study can also be applied in an organism agnostic manner for surveillance in the hospital, improving our ability to contain and prevent nosocomial outbreaks.

Computed tomography of the head for adult patients with minor head injury: are clinical decision rules a necessary evil?

INTRODUCTION: This study aimed to evaluate compliance with and performance of the Canadian Computed Tomography Head Rule (CCHR), and its applicability to the Singapore adult population with minor head injury. METHODS: We conducted a retrospective study over six months of consecutive patients who presented to the adult emergency department (ED) with minor head injury. Data on predictor variables indicated in the CCHR was collected and compliance with the CCHR was assessed by comparing the recommendations for head computed tomography (CT) to its actual usage. RESULTS: In total, 349 patients satisfied the inclusion criteria. Common mechanisms of injury were falls (59.3%), motor vehicle crashes (16.9%) and assault (12.0%). 249 (71.3%) patients underwent head CT, yielding 42 (12.0%) clinically significant findings. 1 (0.3%) patient required neurosurgical intervention. According to the CCHR, head CT was recommended for 209 (59.9%) patients. Compliance with the CCHR was 71.3%. Among the noncompliant group, head CT was overperformed for 20.1% and underperformed for 8.6% of patients. Multivariate logistic regression analysis revealed that absence of retrograde amnesia (odds ratio [OR] 4.1, 95% confidence interval [CI] 1.8-9.7) was associated with noncompliance to the CCHR. Factors associated with underperformance were absence of motor vehicle crashes as a mechanism of injury (OR 6.6, 95% CI 1.2-36.3) and absence of headache (OR 10.8, 95% CI 1.3-87.4). CONCLUSION: Compliance with the CCHR for adult patients with minor head injury remains low in the ED. A qualitative review of physicians' practices and patients' preferences may be carried out to evaluate reasons for noncompliance.

Atypical Essex-Lopresti injury of the forearm: a case report.

The Essex-Lopresti injury of the forearm is difficult to diagnose. A missed diagnosis can lead to persistent pain and instability of the wrist. We report a 33-year-old man with a pre-existing cubital varus deformity who sustained an atypical Essex-Lopresti injury after a fall on his elbow. Accurate diagnosis requires understanding of force transmission and anatomy of the radius and ulna, as well as the proximal and distal radioulnar joints as a unit.