Factors influencing the stewardship activities of Antimicrobial Management Teams: a national cross-sectional survey.

BACKGROUND: The link between inappropriate antibiotic prescribing and the global threat of antimicrobial resistance is well documented. International strategies recommend antimicrobial stewardship (AMS) programmes, with improvement interventions to safeguard antibiotics. AIM: This study sought to systematically evaluate the impact of multi-professional Antimicrobial Management Team (AMT) staff resource availability on stewardship activities. METHODS: We conducted an on-line, cross-sectional survey of AMTs in each regional Health Board and the national specialist hospital in Scotland (N = 15). Responses were analysed descriptively, exploring observed relationships between variables to identify patterns. FINDINGS: Results highlighted apparent variation in the levels of AMT resource availability across Scotland, not directly influenced by Health Board size, with some larger Health Boards having proportionately poorer AMT resource allocation. However, the range and frequency of activities to support AMS was not directly linked to either Health Board size or staff resource allocation, indicating a more complex inter-relationship between factors. CONCLUSIONS: There is apparent inequity in staff resource available for AMTs across Scotland, with significantly lower resource allocation in comparison with recommendations from other international studies. However, considering these survey findings with our earlier qualitative research indicates that leadership style and team member enthusiasm may be as, if not more, influential than resource availability on the scope of AMT activities. These findings have international relevance for hospital service managers considering the recruitment, training and ongoing support of AMTs, in order to maximize impact from a limited resource.

Establishing a baseline for a national paediatric antimicrobial stewardship programme.

BACKGROUND: The majority of antimicrobial stewardship programmes focus on prescribing in adult populations; however, there is a recognized need for targeted paediatric antimicrobial stewardship to improve the quality and safety of prescribing amongst this patient group. OBJECTIVES: To describe the current epidemiology of antimicrobial prescribing in paediatric inpatient populations in Scotland to establish a baseline of evidence and identify priority areas for quality improvement to support a national paediatric antimicrobial stewardship programme. METHODS: A total of 559 paediatric inpatients were surveyed during the Scottish national point prevalence survey of healthcare-associated infections and antimicrobial prescribing, 2016. The prevalence of antimicrobial prescribing was calculated and characteristics of antimicrobial prescribing were described as proportions and compared between specialist hospitals and paediatric wards in acute hospitals. RESULTS: Prevalence of antimicrobial use in paediatric inpatients was 35.4% (95% CI = 31.6%-39.4%). Treatment of community- and hospital-acquired infections accounted for 47.1% and 20.7% of antimicrobial use, respectively, with clinical sepsis being the most common diagnosis and gentamicin the most frequently prescribed antimicrobial for the treatment of infection. The reason for prescribing was documented in the notes for 86.5% of all prescriptions and, of those assessed for compliance against local policy, 92.9% were considered compliant. CONCLUSIONS: Data from national prevalence surveys are advantageous when developing antimicrobial stewardship programmes. Results have highlighted differences in the prescribing landscape between paediatric inpatient populations in specialist hospitals and acute hospitals, and have informed priorities for the national antimicrobial stewardship programme, which reinforces the need for a targeted paediatric antimicrobial stewardship programme.

Development of consensus-based national antimicrobial stewardship competencies for UK undergraduate healthcare professional education.

BACKGROUND: Healthcare professionals are involved in an array of patient- and medicine-related stewardship activities, for which an understanding and engagement with antimicrobial stewardship (AMS) is important. Undergraduate education provides an ideal opportunity to prepare healthcare professionals for these roles and activities. AIM: To provide UK national consensus on a common set of antimicrobial stewardship competencies appropriate for undergraduate healthcare professional education. METHODS: A modified Delphi approach comprising two online surveys delivered to a UK national panel of 21 individuals reflecting expertise in prescribing and medicines management with regards to the education and practice of nurses and midwives, pharmacists, physiotherapists, and podiatrists; and antimicrobial prescribing and stewardship. Data collection took place between October and December 2017. FINDINGS: A total of 21 participants agreed to become members of the expert panel, of whom 19 (90%) completed round 1 questionnaire, and 17 (89%) completed round 2. Panelists reached a consensus, with consistently high levels of agreement reached, on six overarching competency statements (subdivided into six domains), and 55 individual descriptors essential for antimicrobial stewardship by healthcare professionals. CONCLUSION: Due to the consistently high levels of agreement reached on competency statements and their associated descriptors, this competency framework should be used to direct education for undergraduate healthcare professionals, and those working in new clinical roles to support healthcare delivery where an understanding of, and engagement with, AMS is important. Although the competencies target basic education, they can also be used for continuing education.

Results from the third Scottish National Prevalence Survey: is a population health approach now needed to prevent healthcare-associated infections?

BACKGROUND: Healthcare-associated infections (HCAIs) are a major public health concern and a significant cause of morbidity and mortality. A robust and current evidence base that is specific to local, national and Europe-wide settings is necessary to inform the development of strategies to reduce HCAI and contain antimicrobial resistance. AIM: To measure the prevalence of HCAI and antimicrobial prescribing and identify key priority areas for interventions to reduce the burden of infection. METHODS: A national rolling point-prevalence survey (PPS) in National Health Service (NHS) acute, NHS non-acute, NHS paediatric, and independent hospitals was carried out between September and November 2016 using the European Centre for Disease Prevention and Control protocol designed for the European PPS. FINDINGS: The prevalence of HCAI was 4.6%, 2.7%, and 3.2% in acute adults, paediatric and non-acute patient groups, respectively. The most frequent HCAI types reported in adult patients were urinary tract infection and pneumonia. The prevalence of antimicrobial prescribing was 35.7%, 29.3%, and 13.8% in acute adults, paediatric, and non-acute patient groups, respectively. Respiratory, skin and soft tissue, gastrointestinal, and urinary tract infections were the most common infections being treated at the time of survey. CONCLUSION: HCAI continues to be a public health concern in Scotland. Urinary tract infection and pneumonia continue to place a significant burden on patients and on healthcare delivery, including those that develop in the community and require hospital admission. A broader population health approach which focuses on reducing the risk of infection upstream would reduce these infections in both community and hospital settings.

The role of extensionists in Santa Catarina, Brazil, in the adoption and rejection of providing pain relief to calves for dehorning.

The majority of dairy calves around the world are dehorned with methods that cause them pain and distress. In some dairy production systems, extensionists may influence dehorning practices used on farm through their advisory and knowledge-transfer role. The aims of this study were to investigate Brazilian extensionists' knowledge, beliefs, and behavior regarding dehorning dairy calves. As little research has addressed this question, a qualitative, theory-building approach was used and the theory of planned behavior was used as a conceptual framework to guide data collection and analysis. In-depth, semi-structured interviews were undertaken with 15 extensionists working in Santa Catarina, Brazil, to examine their role in the adoption and rejection of pain-mitigation strategies at dehorning. The interview transcripts were free coded, identifying 9 major themes within and across interviews. Transcribed interview responses were then coded to constructs in the theory of planned behavior. The themes and constructs that emerged through analysis of the interview responses were combined to develop a conceptual model of extensionists' beliefs, attitudes, and behavior toward recommending protocols for dehorning aimed at minimizing pain. The extensionists interviewed believed that it was necessary to dehorn all dairy replacement heifers. Despite being aware of methods to minimize pain during and after dehorning, all of the interviewees recommended or used the hot cautery method, with no pain control. This method was described as the most effective, cheapest, safest, and fastest method of dehorning. The majority (12) of interviewees rejected the caustic paste method, citing negative past experiences or unfamiliarity with the method and the belief that the method is less practical and riskier for farmers. More than half of the interviewees did not recognize dehorning as painful or expressed the belief that the pain associated with the procedure did not justify the use of pain control. Although a small number of extensionists (4) recognized potential sources of social pressure to change, including the rejection of pain-inflicting practices by some farmers, the Brazilian general public, and animal-protection societies, they did not identify these factors as a reason to change their existing practices. Interviewees expressed the belief that the adoption of practices to minimize pain and stress, such as dehorning very young calves, using caustic paste and pain control, would increase labor and costs associated with dehorning. Extensionists' negative attitudes toward recommending practices that minimize pain during and after dehorning appear to be embedded in the production-focused political and economic agriculture environment and a lack of education, research, and legislation regarding farm animal welfare.

In vitro study of the effectiveness of different dressings for debriding fibrin in blood clots from horses.

Franz diffusion cells containing uniformly dehydrated equine blood clots to simulate fibrinous eschar were used to measure the rate of debridement of fibrin by novel and traditional wound dressings, under standardised conditions of temperature, pH and humidity. Significant increases in protein breakdown occurred within 24 hours with all the dressings, but not thereafter. In general, dressings hydrated in normal saline were better as debriding agents than dressings hydrated in water. Autolytic debriding agents were 47 per cent more effective than chemical debriding agents; specifically, hydrofibre and gauze dressings hydrated in saline broke down more than 3500 microg/ml of protein whereas dressings impregnated with proteolytic enzymatic agents digested less than 1400 microg/ml.

Mucosal surface area and fermentation activity in the hind gut of hydrated and chronically dehydrated working donkeys.

The effects of mild chronic dehydration on fermentation rate and mucosal surface area in the cecum, dorsa and ventral colon, and descending colon of the hindgut were investigated in South African donkeys (n = 11) in agricultural work. Dehydration representing a 6% drop in BW (n = 6) was associated with increased fermentation activity in the cecum (252 +/- 22.9 vs. 161 +/- 13.5 micromol/g of DM.h(-1), P < 0.01) and enhanced fluid retention in the ventral colon (0.81 +/- 0.026 vs. 0.73 +/- 0.034 mL/g gut, P < 0.05). Fermentation activity in the next segment of the hindgut, the ventral colon, of dehydrated donkeys was also greater numerically (92.5 +/- 22.60 vs. 77.9 +/- 10.40 micromol/g of DM.h(-1)), but this difference was not significant. Total mucosal and crypt surface area per unit volume of gut (Sv, microm2/microm3) was greater in dehydrated donkeys for the cecum (253 +/- 23.0 vs. 161 +/- 13.5, P < 0.01), the ventral colon (286 +/- 6.2 vs. 171 +/- 9.8, P < 0.01), the dorsal colon (276 +/- 18.2 vs. 256 +/- 11.0, P < 0.05), and the descending colon (260 +/- 20.3 vs. 191 +/- 15.2, P < 0.05). Enhanced fermentation activity and enhanced mucosal absorptive or secretory capacity within the hindgut during chronic dehydration was associated with an observed maintenance of appetite. These adaptations in the hindgut are valuable physiological attributes for working donkeys in semi-arid regions where they are frequently exposed to chronic dehydration.

A descriptive study of urban rabies during the civil war in Sierra Leone: 1995-2001.

A study was conducted to assess the effects of the breakdown in internal infrastructure on the incidence of canine-transmitted human rabies in urban areas of Sierra Leone during the course of the civil war between 1995 and 2001. Data from provincial hospitals in the Western Area and Southern Province indicated that there was a significant increase in the incidence of canine-transmitted urban human rabies chi2 = 39.63, p < 0.0001, particularly among children chi2 = 23.73, p < 0.0001, over the course of the war. In the Western Area in 2001, towards the end of the war, there was a significant increase in adult cases, which was reflected in the observed versus the expected chi2 ratio (70 versus 53). Interview-based questionnaire surveys in Freetown administered between 2001 and 2002 indicated that dogs were commonly kept for security reasons, and were largely unrestrained and unlicensed, regardless of the socioeconomic status of the owner. Virtually all dogs were unvaccinated and were mainly living in close proximity with humans. This study indicated that there is an urgent requirement for appropriate mass rabies vaccination campaigns for pet dogs and for campaigns to manipulate the urban habitat to control free-roaming and wandering but owned dog populations in Freetown and other urban areas in the provinces of Sierra Leone. Interview-based questionnaires administered in three districts of Freetown indicated a relatively high degree of uniformity in dog husbandry and veterinary care habits across a wide range of socioeconomic status categories in dog owners.

Manganese species migration in soil at the Sabine National Wildlife Refuge, Louisiana.

A modified sequential extraction procedure was employed to speciate the chemical forms of Mn in sediment using flame atomic absorption spectrophotometry. Concentrations were determined in five different fractions for each sample (Mn in the exchangeable form, bound to carbonates, bound to Mn/Fe oxides, bound to organic matter and in the residual form). The determinations were made for sediments obtained from the Sabine National Wildlife Refuge while a marshland reclamation project was being conducted. Sediment samples were taken from Ship Channel dredge spoils (thought to be contaminated), an old reclamation site, a new reclamation site and a reference site. The results indicated that the Ship Channel sediments were not contaminated, but revealed an Mn "pumping" model, which proposes that additional Mn added to a similar site is concentrated near the surface soil layers by environmental conditions, which may be a cause of the observed slow recovery of vegetation at one of the more recently developed sites.

Post-operative endophthalmitis: the application of hazard analysis critical control points (HACCP) to an infection control problem.

Hazard analysis critical control points (HACCP) is a quality assurance system widely used in the food industry to ensure safety. We adopted the HACCP approach when conventional infection control measures had failed to solve an ongoing problem with an increased incidence of postoperative endophthalmitis, and our ophthalmology unit was threatened with permanent cessation of intraocular surgery. Although time-consuming, the result was an entirely new set of protocols for the care of patients undergoing intraocular surgery, the development of an integrated care pathway, and a comprehensive and robust audit programme, which enabled intraocular surgery to continue in a new spirit of confidence. HACCP methodology has so far been little used in healthcare, but it might be usefully applied to a variety of apparently intractable infection control problems.

Determination of cadmium, lead, and nickel by simultaneous multielement flame atomic absorption spectrometry in burned and unburned Venezuelan crude oil.

This work describes the use of simultaneous multielement flame atomic absorption spectrometry for the determination of cadmium, lead, and nickel in burned and unburned Venezuelan crude oil (5 ml volumes) in controlled laboratory experiments. The simultaneous detection limits were 0.010 mug ml(-1) (Cd), 0.04 mug ml(-1) (Pb), and 0.40 mug ml(-1) (Ni) with precision's of these elements at concentrations of 10x above these detections limits, and in the crude oil, of 1-2%. Loss of elemental concentrations in the crude oil in a 3-5 ml volume when burned were 4% (Cd), 50% (Pb), and 22% (Ni). These results suggest that the form of the elements and the temperature attained in the burning crude oil effect the removal of the elements. The type of surface affected the volume of oil removed. Soil gave a 15% and a smooth surface almost 50% volume reduction.

Control of infection: a survey of general medical practices.

BACKGROUND: The aims of the study were (1) to assess current infection control practice within general medical practices and establish a base line; (2) to identify potential infection control problems; (3) to assess the need for local infection control guidelines or standards related to general medical practice; (4) to assess the need for educational provision. METHODS: A survey was carried out, using questionnaire and structured interviews, of all general practices (92) within a Health Board area with a patient population of 561,300. RESULTS: Forty two (46 per cent) practices participated, serving 67 per cent of the patient population. Only three (7 per cent) practices had written infection control policies and only six (14 per cent) provided training on the subject. Thirty (71 per cent) practices had autoclaves; however, performance monitoring was poor. The majority of high-risk instruments were adequately decontaminated; of the medium-risk instruments, the auriscope speculum was the item most frequently inadequately treated [36 practices (88 per cent)]. Deficiencies were identified in treatment of blood spillage, and protective clothing provision was variable. The majority, 40 (95 per cent) practices, had systems to deal with clinical waste; however, only two (5 per cent) reported use of BS7320 sharps containers on domiciliary visits. Despite the recognized dangers, 23 (55 per cent) practices resheathed needles and only six (14 per cent) had first aid guidance for needlestick injuries. Only eight (19 per cent) practices knew and recorded staff immunity to hepatitis B following vaccination. CONCLUSIONS: Some deficiencies in infection control practice were identified and the need for policy guidance and staff training was highlighted.

Frameshift mutation in codon 176 of the p53 gene in rat esophageal epithelial cells transformed by benzo[a]pyrene dihydrodiol.

Mutations in the p53 tumor suppressor gene have been associated with exposure to environmental chemical carcinogens. Cultured rat esophageal epithelial cells were transformed in vitro by treatment with benzo[a]pyrene dihydrodiol (BP-DHD). A BP-DHD-transformed cell line and control cell lines were analyzed for mutations in the p53 gene and in the Ha-ras gene by single-strand conformation polymorphism analysis of polymerase chain reaction-amplified products and direct DNA sequencing. The deletion of one cytosine in codons 174-176 (TGCCCCCAC-->TGCCCCAC) of the p53 gene was found only in the BP-DHD-transformed cell line. The BP-DHD-transformed cells were highly invasive and tumorigenic when transplanted into syngeneic rats, whereas control lines either were nontumorigenic or formed epithelial cysts. BP-DHD-transformed cells and control lines were negative for mutations in the Ha-ras gene. Our results suggest that the tumorigenic potential of the BP-DHD-transformed cell line is associated with a frameshift mutation in codon 176 of the p53 gene but not with mutations in the Ha-ras gene. The G/C-rich codons 174-176 in the rat p53 gene may be specific targets for BP-DHD.

Exercise induced vasodepressor syncope.

Five cases of exercise induced pure vasodepressor syncope in patients without significant structural heart disease are reported. Hypotension and symptoms of syncope or pre-syncope were induced by treadmill exercise testing and in each case limited exercise performance. Evidence of inappropriate peripheral vasodilation, probably as a consequence of ventricular mechanoreceptor stimulation, was shown in all five patients. Head up tilt testing resulted in hypotension in four patients and isoprenaline infusion in the supine position resulted in hypotension in the fifth. These patients had a new condition of exercise induced neurally mediated (vasodepressor) syncope without appreciable structural cardiac abnormalities.

Effect of subcutaneous nicotine injections of EEG alpha frequency in non-smokers: a placebo-controlled pilot study.

The effect of two subcutaneous injections of 0.6 mg nicotine, administered 40 min apart, was compared with placebo in four non-smoking subjects in a counter-balanced double-blind crossover design. The nicotine injections produced mean peak plasma nicotine concentrations of 5.3 ng/ml 10 min after the first injection and 8.5 ng/ml 10 min after the second injection. The nicotine injections produced an increase in mean dominant alpha frequency on the electroencephalogram (EEG) which was 2 Hz greater than the effect of placebo (P = 0.049) and also produced a heart-rate boost which was 8 beats per minute greater than that produced by placebo (P = 0.022). These effects on dominant alpha frequency and heart rate were most apparent in the 10 min following each nicotine injection. The increase in dominant alpha frequency found in non-smokers in this study was similar to that following nicotine inhalation in abstinent smokers in previous studies, and suggests that this is a primary effect of nicotine, rather than simply a reversal of withdrawal-induced EEG slowing.

Decreased heart rate variability in survivors of sudden cardiac death not associated with coronary artery disease.

BACKGROUND: Although heart rate variability has already been studied in survivors of sudden cardiac death secondary to coronary artery disease, an assessment of heart rate variability in survivors of sudden cardiac death not associated with coronary artery disease has not been made. METHODS: 10 patients with aborted sudden cardiac death not associated with coronary artery disease (seven patients with primary ventricular fibrillation and three with unclassified mild cardiomyopathy) underwent two channel 24 hour Holter monitoring in a drug free state. All subjects were in sinus rhythm and had normal atrioventricular conduction and normal cardiac function. Spectral heart rate variability was analysed on a Holter analysis system and was expressed as total (0.01-1.00 Hz), low (0.04-0.15 Hz) and high (0.15-0.40 Hz) frequency components for each hour. Heart rate variability index was calculated for the 24 hour periods. 10 age and sex matched healthy subjects were taken as a control group. RESULTS: The spectral heart rate variability over 24 hours was significantly lower in survivors of sudden cardiac death than in controls (total 38(15) v 48(14) ms; low, 25(11) v 32(13) ms; and high, 13(8) v 18(8) ms; p < 0.05 for all comparisons). The differences in the ratio of low/high (2.19(0.76) v 1.98(0.50), p = 0.132), mean heart rate (77(12) v 69(12) beats/min, p = 0.070), and heart rate variability index (38(12) v 44(16), p = 0.287) over 24 hours between survivors of sudden cardiac death and controls did not reach significance. Comparisons of the hourly heart rate variability over the 24 hour period between the two groups showed that the differences in all components of heart rate variability, low/high ratio and mean heart rate were highly significant. Furthermore, there was no significant difference in the maximum hourly heart rate variability over the 24 hour period. The minimum hourly heart rate variability was, however, significantly lower in survivors of sudden cardiac death than in controls (total, 20(8) v 28(4) ms; low, 12(6) v 17(3) ms; high, 6(2) v 8(2) ms; p < 0.05 for all comparisons). CONCLUSIONS: These findings suggest that there is abnormal autonomic influence on the heart in patients without coronary artery disease at risk of sudden cardiac death. Hourly analysis of heart rate variability throughout the 24 hour period may provide additional information important in the identification of high risk patients.