The Use of the TARGET Antibiotic Checklist to Support Antimicrobial Stewardship in England's Community Pharmacies.

Antimicrobial Stewardship (AMS) requires effective teamwork between healthcare professionals, with patients receiving consistent messages from all healthcare professionals on the appropriate antimicrobial use. Patient education may reduce patients' expectations to receive antibiotics for self-limiting conditions and reduce the pressure on primary care clinicians to prescribe antibiotics. The TARGET Antibiotic Checklist is part of the national AMS resources for primary care and aims to support interaction between community pharmacy teams and patients prescribed antibiotics. The Checklist, completed by the pharmacy staff with patients, invites patients to report on their infection, risk factors, allergies, and knowledge of antibiotics. The TARGET antibiotic checklist was part of the AMS criteria of England's Pharmacy Quality Scheme for patients presenting with an antibiotic prescription from September 2021 to May 2022. A total of 9950 community pharmacies claimed for the AMS criteria and 8374 of these collectively submitted data from 213,105 TARGET Antibiotic Checklists. In total, 69,861 patient information leaflets were provided to patients to aid in the knowledge about their condition and treatment. 62,544 (30%) checklists were completed for patients with an RTI; 43,093 (21%) for UTI; and 30,764 (15%) for tooth/dental infections. An additional 16,625 (8%) influenza vaccinations were delivered by community pharmacies prompted by discussions whilst using the antibiotic checklist. Community pharmacy teams promoted AMS using the TARGET Antibiotic Checklist, providing indication-specific education and positively impacting the uptake of influenza vaccinations.

The National Implementation of a Community Pharmacy Antimicrobial Stewardship Intervention (PAMSI) through the English Pharmacy Quality Scheme 2020 to 2022.

Since 2020, England's Pharmacy Quality Scheme (PQS) has incentivised increased antimicrobial stewardship (AMS) activities in community pharmacy. In 2020/21, this included the requirement for staff to complete an AMS e-Learning module, pledge to be an Antibiotic Guardian and develop an AMS Action plan. To build and embed these initiatives, in 2021/22, the PQS required the use of the TARGET Antibiotic Checklist (an AMS tool for use when patients present with a prescription for antibiotics to support conducting and recording of a series of safety and appropriateness checks against each prescribed antibiotic). This paper describes the implementation of the national PQS criteria from 2020 to 2022, and details community pharmacies' AMS activities and barriers to implementation of the 2021/22 criteria. A total of 8374 community pharmacies submitted data collected using the TARGET Antibiotic Checklist for 213,105 prescriptions; 44% surpassed the required number for the PQS. Pharmacy teams reported checking the following: duration, dose, and appropriateness of antibiotics; patient allergies and medicine interactions (94-95%); antibiotic prescribing guideline adherence (89%); and the patient's previous use of antibiotics (81%). The prescriber was contacted for 1.3% of TARGET Antibiotic Checklists (2741), and the most common reasons for such contacts were related to dose, duration, and possible patient allergy. A total of 105 pharmacy staff responded to a follow-up questionnaire, which suggested that some AMS principles had been embedded into daily practice; however, the necessary time commitment was a barrier. The PQS was able to incentivise mass AMS activities at pace over consecutive years for England's community pharmacies simultaneously. Future research should monitor the continuation of activities and the wider impacts on primary care.

Patients' and Healthcare Professionals' Experiences and Views of Recurrent Urinary Tract Infections in Women: Qualitative Evidence Synthesis and Meta-Ethnography.

BACKGROUND: Urinary tract infections (UTIs) are a common and significant problem for patients, clinicians, and healthcare services. Recurrent UTIs (rUTIs) are common, with a 3% prevalence in the UK. Although acute UTIs have a significant negative impact on the lives of patients, evidence of the impact of rUTIs is limited. To enhance shared decision-making around rUTI management, it is important to understand both the patients' and healthcare professionals' (HCPs') perspectives. The objective of this qualitative evidence synthesis is to understand patients' and HCPs' experiences and views in the management of rUTIs. METHODS: A qualitative evidence synthesis (QES) was performed that included primary qualitative studies involving patients with rUTIs or primary care HCPs who manage patients with rUTIs, up to June 2022. The following databases were searched: MEDLINE, Embase, CINAHL, PsycInfo, ASSIA, Web of Science, Cochrane Database of Systematic Reviews, Epistemonikos, Cochrane Central Registry of Controlled Trials, OpenGrey, and the Health Management Information Consortium (HMIC). The QES was prospectively registered on PROSPERO (CRD42022295662). Reciprocal translation was conducted and developed into a line of argument synthesis. We appraised the confidence in our review findings by using GRADE-CERQual. RESULTS: Twelve studies were included in the final review; ten of those included patients, and three included HCPs (one study included both). Our review demonstrates that women with rUTIs have a unique experience, but it is generally of a chronic condition with significant impacts on numerous aspects of their lives. Antibiotics can be "transformative", but patients have serious concerns about their use and feel non-antibiotic options need further research and discussion. HCPs share similar views about the impacts of rUTIs and concerns about antibiotic use and find the management of rUTIs to be complex and challenging. Based on our GRADE-CERQual assessment of the review findings, we have moderate confidence in those related to patients and low confidence in those related to HCPs. New conceptual models for both patients and HCPs are presented. CONCLUSIONS: This review has significant clinical implications. Patients require information on antibiotic alternative acute and preventative treatments for rUTIs, and this is not currently being addressed. There are communication gaps around the impact of rUTIs on patients, their perceived expectation for antibiotics, and the reasons for treatment failure. Further development of current clinical guidance and a patient decision aid would help address these issues.

Mixed-Method Evaluation of a Community Pharmacy Antimicrobial Stewardship Intervention (PAMSI).

The community pharmacy antimicrobial stewardship intervention (PAMSI) is multi-faceted and underpinned by behavioural science, consisting of the TARGET Antibiotic Checklist, staff e-Learning, and patient-facing materials. This mixed-method study evaluated the effect of PAMSI on community pharmacy staffs' self-reported antimicrobial stewardship (AMS) behaviours. Data collection included staff pre- and post-intervention questionnaires, qualitative interviews, and TARGET Antibiotic Checklists. Quantitative data were analysed by a multivariate ordinal linear mixed effect model; qualitative data were analysed thematically. A total of 101 staff participated from 66 pharmacies, and six completed semi-structured interviews. The statistical model indicated very strong evidence (p < 0.001) that post-intervention, staff increased their antibiotic appropriateness checks and patient advice, covering antibiotic adherence, antibiotic resistance, infection self-care, and safety-netting. Staff reported feeling empowered to query antibiotic appropriateness with prescribing clinicians. The TARGET Antibiotic Checklist was completed with 2043 patients. Topics patients identified as requiring advice from the pharmacy team included symptom duration, alcohol and food consumption guidance, antibiotic side-effects, and returning unused antibiotics to pharmacies. Pharmacy staff acknowledged the need for improved communication across the primary care pathway to optimise antimicrobial use, and PAMSI has potential to support this ambition if implemented nationally. To support patients not attending a pharmacy in person, an online information tool will be developed.

Development and pilot evaluation of an educational programme on infection prevention and antibiotics with English and Scottish youth groups, informed by COM-B.

BACKGROUND: The UK 5-year antimicrobial resistance (AMR) National Action Plan highlights the need to prevent community infections through education of children. Activities around infection prevention (IP) and antibiotics were piloted by UK youth groups in 2016-2018, prompting Public Health England (PHE) to develop a standardised programme. The aim of the study was to develop and pilot an educational programme on IP and antibiotics for use by community youth groups in the UK. METHODS: A working group, including youth group volunteers interested in IP and AMR, agreed on the programme content through consensus, informed by the Capability, Opportunity, Motivation, Behaviour model (COM-B). The Antibiotic Guardian Youth Badge (AGYB) included learning through interactive e-Bug activities on IP and prudent antibiotic use, action setting through Antibiotic Guardian pledges and consolidation through poster development. The programme was piloted and evaluated with conveniently recruited youth groups in 2019, including quantitative and qualitative questionnaire feedback from community leaders and children. RESULTS: Fourteen youth group leaders and 232 children from uniformed Girlguiding/Scout groups in England and Scotland participated in the pilot evaluation, as well as two primary schools. Leaders reported alignment to the themes of their youth organisation, but struggled to teach antibiotics and antibiotic resistance. Children reported enjoyment and intentions to improve hygiene behaviour. CONCLUSION: Community youth groups are a suitable setting for IP and antibiotics education. The AGYB was officially launched in March 2020 and promoted for use with home-schooling children and remote youth group meetings to educate about IP during the coronavirus disease 2019 (COVID-19) pandemic.

Empowering Patients to Self-Manage Common Infections: Qualitative Study Informing the Development of an Evidence-Based Patient Information Leaflet.

Common self-limiting infections can be self-managed by patients, potentially reducing consultations and unnecessary antibiotic use. This qualitative study informed by the Theoretical Domains Framework (TDF) aimed to explore healthcare professionals' (HCPs) and patients' needs on provision of self-care and safety-netting advice for common infections. Twenty-seven patients and seven HCPs participated in semi-structured focus groups (FGs) and interviews. An information leaflet was iteratively developed and reviewed by participants in interviews and FGs, and an additional 5 HCPs, and 25 patients (identifying from minority ethnic groups) via online questionnaires. Qualitative data were analysed thematically, double-coded, and mapped to the TDF. Participants required information on symptom duration, safety netting, self-care, and antibiotics. Patients felt confident to self-care and were averse to consulting with HCPs unnecessarily but struggled to assess symptom severity. Patients reported seeking help for children or elderly dependents earlier. HCPs' concerns included patients' attitudes and a lack of available monitoring of advice given to patients. Participants believed community pharmacy should be the first place that patients seek advice on common infections. The patient information leaflet on common infections should be used in primary care and community pharmacy to support patients to self-manage symptoms and determine when further help is required.

Knowledge and attitudes of adolescents towards the human microbiome and antibiotic resistance: a qualitative study.

Background: Antibiotic and dietary behaviour affect the human microbiome and influence antibiotic resistance development. Adolescents are a key demographic for influencing knowledge and behaviour change. Objectives: To explore adolescents' knowledge and attitudes towards the microbiome and antibiotic resistance, and the capability, motivation and opportunity for educators to integrate microbiome teaching in schools. Methods: Qualitative study informed by the Theoretical Domains Framework (TDF) and COM-B model. Six educational establishments were purposively selected by rural/city and socioeconomic status, within Gloucestershire, South West England in 2019. Forty 14-18-year olds participated in focus groups, and eight science or health educators participated in interviews. Data were analysed thematically, double-coded and mapped to the TDF/COM-B. Results: Adolescents were aware of 'good microbes' in the body but lacked deeper knowledge. Adolescents' knowledge of, and intentions to use, antibiotics appropriately differed by their levels of scientific study. Adolescents lacked knowledge on the consequences of diet on the microbiome, and therefore lacked capability and motivation to change behaviour. Educators felt capable and motivated to teach microbiome topics but lacked opportunity though absence of topics in the national curriculum and lack of time to teach additional topics. Conclusions: A disparity in knowledge of adolescents needs to be addressed through increasing antibiotic and microbiome topics in the national curriculum. Public antibiotic campaigns could include communication about the microbiome to increase awareness. Educational resources could motivate adolescents and improve their knowledge, skills and opportunity to improve diet and antibiotic use; so, supporting the UK antimicrobial resistance (AMR) national action plan.

Is sharing the TARGET respiratory tract infection leaflet feasible in routine general practice to improve patient education and appropriate antibiotic use? A mixed methods study in England with patients and healthcare professionals.

BACKGROUND: Patient education on treatment choices for common respiratory tract infections (RTIs) is important to encourage appropriate antibiotic use. Evidence shows that use of leaflets about RTIs can help reduce antibiotic prescribing. TARGET leaflets facilitate patient-clinician communication in consultations. AIM: To explore patient, healthcare professional (HCP) and general practice (GP) staff views on the current Treating Your Infection (TYI)-RTI leaflet and proposed new 'antibiotic effect' column aimed at sharing information on the limited effect antibiotics have on the duration of RTIs. METHODS: Service evaluation underpinned by Com-B behavioural framework, using patient and HCP questionnaires, and GP staff interviews/focus groups. RESULTS: Patients completed 83 questionnaires in GP waiting rooms. A lack of patient understanding about usual illness duration influenced their use of antibiotics for some RTIs. Patients provided positive feedback about the leaflet, reporting it increased their capability to self-care, re-consult when necessary and increase understanding of illness duration. Patients indicated they would value information on the difference antibiotics can make to illness duration. In total, 43 HCP questionnaires were completed and 16 GP staff participated in interviews/focus groups. Emerging themes included: barriers and facilitators to leaflet use; modifications; and future dissemination of the leaflet. GP staff stated that the 'antibiotic effect' column should not be included in the leaflet. CONCLUSION: Patient education around usual illness duration, side effects of antibiotics and back-up prescriptions gives patients a greater control of their infection management. As GP staff opposed the extra information about benefits of antibiotics on illness duration, this will not be added.