Responding to Urinary Tract Infection Symptoms in England's Community Pharmacies.

Most urinary tract infections (UTIs) are self-limiting and frequently present in primary care; it is common for patients to seek symptom relief. The TARGET Treating Your Infection (TYI) leaflet was used to respond to UTI symptoms for women under 65 years presenting in community pharmacies. The widespread use of these leaflets was incentivised as part of NHS England's Pharmacy Quality Scheme (PQS) 2022-23, between October 2022 and March 2023. The TARGET TYI leaflets are aimed to support appropriate antibiotic use and antimicrobial stewardship (AMS) as well as reducing the opportunity for resistance to develop. A total of 8363 community pharmacies completed the AMS criteria within the PQS and collectively submitted data for 104,142 patients presenting with UTI symptoms. The majority, 77% (75,071), of (non-pregnant) women presented with none or only one of the three strongly predictive symptoms of dysuria, new nocturia, cloudy urine, and/or vaginal discharge and, therefore, were less likely to have a UTI, as outlined in the English UTI diagnostic guidance. Conversely, 23% (22,381) of women presented with two or more symptoms of dysuria, new nocturia, cloudy urine, and with no vaginal discharge and, therefore, they were more likely to have a UTI. The TARGET TYI UTI leaflets support community pharmacy teams to differentiate between symptoms more likely to be associated with UTIs and those that could be managed with self-care. The findings suggest that most women presenting to community pharmacies with urinary symptoms were likely to have self-limiting symptoms, and could be suitably managed with self-care, pain relief, and appropriate safety netting. Approximately one-third of patients were managed by community pharmacy team members without the need for referral to a pharmacist and one in five patients presented with escalation symptoms and were signposted to other healthcare settings. A total of 94% (97,452) of women received self-care advice of which 36% (37,565) were also provided with additional patient information leaflets.

Perceived current and future roles of UK-based community pharmacy professionals in the long-term management of acne.

Introduction: Acne is a common skin condition treated in community pharmacy but moderate to severe cases may need referral to general practice for treatment that may include topical or oral antimicrobial treatments. Pharmacy teams working in the community are well-placed to manage acne treatments in line with NICE guidance. Objectives: To explore the perceived current and future roles of community pharmacy (CP) teams alongside needs to achieve potential future roles. Additionally, usefulness of the TARGET acne 'How to' toolkit to support these roles was sought. Methods: A mixed-methods electronic survey of UK-based CP professionals and stakeholders in March 2023. Results: 54 pharmacy professionals and stakeholders responded to the survey. The current confidence of pharmacy professionals in managing acne was rated as moderate and reviewing long-term medications for acne prescribed by another healthcare professional was seen as a future role. The needs identified to undertake such a role were: training, availability of prescribing or supply frameworks, and appropriate remuneration. The TARGET acne resources were thought of as being very useful for acne management. Conclusions: Potential future roles for CP have been identified, alongside additional needs to undertake these roles; the TARGET acne 'How to' resources could support pharmacy professionals in the management and review of antimicrobial treatment for acne.

Changes in public health-seeking behaviours for self-limiting respiratory tract infections across England during the COVID-19 pandemic.

BACKGROUND: National Health Service (NHS) guidance for acute respiratory tract infections (RTIs) advocates self-care, encourages utilization of local pharmacies and recommends consulting general practitioners (GPs) primarily for the vulnerable or those with persistent symptoms. Coronavirus disease 2019 exerted substantial strain on the English NHS, affecting public access to primary care services. METHODS: For 3 years, public surveys assessed RTI incidences in the previous 12 months and associated health-seeking behaviours. Telephone surveys of 1676 respondents across England were conducted in March 2021 and 1663 respondents in March 2022. Findings were compared with a face-to-face baseline survey of 2022 respondents from March 2020. Key demographics were representative of the population. RESULTS: In 2021, the proportion of respondents who reported an RTI (51%) significantly declined from 2020 (70%, P < 0.05), then returned to pre-pandemic rates in 2022 (67%). Respondents reported more proactive symptom management in both 2021 and 2022 from 2020: there were greater reports of seeking over-the-counter treatments (55%, 55% vs. 35%, P < 0.05) and use of alternative remedies (38%, 38% vs. 21%, P < 0.05). 2022 observed a reduction in those who reported consulting their GP for their most recent RTI (15%) compared to 2021 (25%, P < 0.05) and 2020 (23%), which was not accounted for through greater consultation rates with other healthcare services. CONCLUSIONS: Public health bodies should consider how pandemic-related changes may have facilitated increased self-care for self-limiting infections such as RTIs. Resources and support must include safety-netting advice to safeguard against unintentional consequences of increased self-care.

Impact of Menopausal Status and Recurrent UTIs on Symptoms, Severity, and Daily Life: Findings from an Online Survey of Women Reporting a Recent UTI.

Introduction: Current UKHSA UTI diagnostic guidance advises empirical antibiotics if two of the following symptoms are present: cloudy urine, dysuria, and new onset nocturia. Hormonal changes during menopause may impact UTI symptoms, and qualitative studies suggest women with recurrent UTIs may present with different UTI symptoms. This study aims to assess whether menopausal status and the presence of recurrent UTIs impact UTI symptoms in women. Methods: An e-survey was conducted between 13 March 2021 and 13 April 2021. Women aged 16 years or older with a history of a UTI in the last year were eligible for inclusion. We defined menopause as those aged 45-64 years; pre-menopause as those less than 45 years; and post-menopause as those 65 years and older. Recurrent UTIs were defined as three or more UTIs in the last year. The data were weighted to be representative of the UK population. Crude unadjusted and adjusted odds ratios were estimated using logistic regression. Results: In total, 1096 women reported a UTI in the last year. There were significant differences in UTI symptoms based on menopausal status and the presence of recurrent UTIs. Post-menopausal women self-reported more incontinence (OR 2.76, 95% CI 1.50,5.09), whereas menopausal women reported more nocturia. Women with recurrent UTIs reported less dysuria, more severe symptoms (OR 1.93 95% CI 1.37,2.73) and a greater impact on daily life (OR 1.68, 95% CI 1.19,2.37). Conclusions: This survey provides evidence that acute UTIs present differently based on menopausal status and in women with recurrent UTIs. It is important that healthcare professionals are aware of these differences when assessing women presenting with an acute UTI and, therefore, further research in this area is needed.

Best practice guidance for antibiotic audit and feedback interventions in primary care: a modified Delphi study from the Joint Programming Initiative on Antimicrobial resistance: Primary Care Antibiotic Audit and Feedback Network (JPIAMR-PAAN).

BACKGROUND: Primary care is a critical partner for antimicrobial stewardship efforts given its high human antibiotic usage. Peer comparison audit and feedback (A&F) is often used to reduce inappropriate antibiotic prescribing. The design and implementation of A&F may impact its effectiveness. There are no best practice guidelines for peer comparison A&F in antibiotic prescribing in primary care. OBJECTIVE: To develop best practice guidelines for peer comparison A&F for antibiotic prescribing in primary care in high income countries by leveraging international expertise via the Joint Programming Initiative on Antimicrobial Resistance-Primary Care Antibiotic Audit and Feedback Network. METHODS: We used a modified Delphi process to achieve convergence of expert opinions on best practice statements for peer comparison A&F based on existing evidence and theory. Three rounds were performed, each with online surveys and virtual meetings to enable discussion and rating of each best practice statement. A five-point Likert scale was used to rate consensus with a median threshold score of 4 to indicate a consensus statement. RESULTS: The final set of guidelines include 13 best practice statements in four categories: general considerations (n = 3), selecting feedback recipients (n = 1), data and indicator selection (n = 4), and feedback delivery (n = 5). CONCLUSION: We report an expert-derived best practice recommendations for designing and evaluating peer comparison A&F for antibiotic prescribing in primary care. These 13 statements can be used by A&F designers to optimize the impact of their quality improvement interventions, and improve antibiotic prescribing in primary care.

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.

Regional and national antimicrobial stewardship activities: a survey from the Joint Programming Initiative on Antimicrobial Resistance-Primary Care Antibiotic Audit and Feedback Network (JPIAMR-PAAN).

Background: Antibiotic overuse and misuse in primary care are common, highlighting the importance of antimicrobial stewardship (AMS) efforts in this setting. Audit and feedback (A&F) interventions can improve professional practice and performance in some settings. Objectives and methods: To leverage the expertise from international members of the Joint Programming Initiative on Antimicrobial Resistance - Primary care Antibiotic Audit and feedback Network (JPIAMR-PAAN). Network members all have experience of designing and delivering A&F interventions to reduce inappropriate antibiotic prescribing in primary care settings. We aim to introduce the network and explore ongoing A&F activities in member regions. An online survey was administered to all network members to collect regional information. Results: Fifteen respondents from 11 countries provided information on A&F activities in their country, and national/regional antibiotic stewardship programmes or policies. Most countries use electronic medical records as the primary data source, antibiotic appropriateness as the main outcome of feedback, and target GPs as the prescribers of interest. Funding sources varied across countries, which could influence the frequency and quality of A&F interventions. Nine out of 11 countries reported having a national antibiotic stewardship programme or policy, which aim to provide systematic support to ongoing AMS efforts and aid sustainability. Conclusions: The survey identified gaps and opportunities for AMS efforts that include A&F across member countries in Europe, Canada and Australia. JPIAMR-PAAN will continue to leverage its members to produce best practice resources and toolkits for antibiotic A&F interventions in primary care settings and identify research priorities.

Attitudes towards coronavirus (COVID-19) vaccine and sources of information across diverse ethnic groups in the UK: a qualitative study from June to October 2020.

OBJECTIVES: Across diverse ethnic groups in the UK, explore attitudes and intentions towards COVID-19 vaccination and sources of COVID-19 information. DESIGN: Remote qualitative interviews and focus groups (FGs) conducted June-October 2020 before UK COVID-19 vaccine approval. Data were transcribed and analysed through inductive thematic analysis and mapped to the Theoretical Domains Framework. SETTING: England and Wales. PARTICIPANTS: 100 participants from 19 self-identified ethnic groups. RESULTS: Mistrust and doubt were reported across ethnic groups. Many participants shared concerns about perceived lack of information about COVID-19 vaccine safety and efficacy. There were differences within each ethnic group, with factors such as occupation and perceived health status influencing intention to accept a vaccine once made available. Across ethnic groups, participants believed that public contact occupations, older adults and vulnerable groups should be prioritised for vaccination. Perceived risk, social influences, occupation, age, comorbidities and engagement with healthcare influenced participants' intentions to accept vaccination once available. All Jewish FG participants intended to accept, while all Traveller FG participants indicated they probably would not.Facilitators to COVID-19 vaccine uptake across ethnic groups included: desire to return to normality and protect health and well-being; perceived higher risk of infection; evidence of vaccine safety and efficacy; vaccine availability and accessibility.COVID-19 information sources were influenced by social factors and included: friends and family; media and news outlets; research literature; and culture and religion. Participants across most different ethnic groups were concerned about misinformation or had negative attitudes towards the media. CONCLUSIONS: During vaccination rollout, including boosters, commissioners and providers should provide accurate information, authentic community outreach and use appropriate channels to disseminate information and counter misinformation. Adopting a context-specific approach to vaccine resources, interventions and policies and empowering communities has potential to increase trust in the programme.

Comparing public knowledge around value of hand and respiratory hygiene, vaccination, and pre- and post-national COVID-19 lockdown in England.

OBJECTIVES: The COVID-19 pandemic spotlighted the importance of infection prevention and control (IPC) measures. Existing literature focuses on healthcare professionals, whereas this article explores changes in public knowledge of IPC, where knowledge is comparably sparse. STUDY DESIGN: National surveys were conducted before (March 2020) and after (March 2021) the COVID-19 lockdown across England. METHODS: A telephone survey of 1676 adults (2021) and a face-to-face survey of 2202 adults (2020) across England were conducted. Key demographics were representative of the population. Weighted logistic regression with composite Wald P-values was used to investigate knowledge change from 2020 to 2021. RESULTS: Compared with 2020, significantly more respondents correctly stated that infections can spread by shaking hands (86% post vs 79% pre; P < .001) and that microbes are transferred through touching surfaces (90% vs 80%; P < .001). More knew that hand gel is effective at removing microbes if water and soap are unavailable (94% vs 92%; P = .015); that when you cough, you may infect other people near you in a room (90% vs 80%; P < .001). Knowledge that vaccination protects others from infection also increased (63% post vs 50% pre; P < .001). There was also significant increase in those confident in their answers. CONCLUSION: Knowledge of IPC measures was higher in 2021 than before the pandemic. Future public health hygiene campaigns should capitalise on this and emphasise that continuing hygiene behaviours, and vaccination can help prevent acquisition and illnesses with other non-COVID-19 infections, thus reducing the strain on the national health service.

Public views of and reactions to the COVID-19 pandemic in England: a qualitative study with diverse ethnicities.

OBJECTIVES: To explore public reactions to the COVID-19 pandemic across diverse ethnic groups. DESIGN: Remote qualitative interviews and focus groups in English or Punjabi. Data were transcribed and analysed through inductive thematic analysis. SETTING: England and Wales, June to October 2020. PARTICIPANTS: 100 participants from 19 diverse 'self-identified' ethnic groups. RESULTS: Dismay, frustration and altruism were reported across all ethnic groups during the first 6-9 months of the COVID-19 pandemic. Dismay was caused by participants' reported individual, family and community risks, and loss of support networks. Frustration was caused by reported lack of recognition of the efforts of ethnic minority groups (EMGs), inaction by government to address COVID-19 and inequalities, rule breaking by government advisors, changing government rules around: border controls, personal protective equipment, social distancing, eating out, and perceived poor communication around COVID-19 and the Public Health England COVID-19 disparities report (leading to reported increased racism and social isolation). Altruism was felt by all, in the resilience of National Health Service (NHS) staff and their communities and families pulling together. Data, participants' suggested actions and the behaviour change wheel informed suggested interventions and policies to help control COVID-19. CONCLUSION: To improve trust and compliance future reports or guidance should clearly explain any stated differences in health outcomes by ethnicity or other risk group, including specific messages for these groups and concrete actions to minimise any risks. Messaging should reflect the uncertainty in data or advice and how guidance may change going forward as new evidence becomes available. A contingency plan is needed to mitigate the impact of COVID-19 across all communities including EMGs, the vulnerable and socially disadvantaged individuals, in preparation for any rise in cases and for future pandemics. Equality across ethnicities for healthcare is essential, and the NHS and local communities will need to be supported to attain this.

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.

What the public in England know about antibiotic use and resistance in 2020: a face-to-face questionnaire survey.

OBJECTIVES: To describe public attitudes and knowledge around antibiotic activity, resistance and use. DESIGN: Face-to-face household 18 question survey using computer-assisted data collection undertaken by Ipsos Market and Opinion Research International. SETTING: Randomly selected households across England, January-February 2020. PARTICIPANTS: 2022 adults (aged 15+,) including 521 black, Asian and minority ethnic (BAME) participants, and 406 aged 15-25 years olds. MAIN OUTCOME MEASURES: Responses to questions about antibiotic activity, resistance and expectations for antibiotics and trust in healthcare professionals. Analyses were weighted to obtain estimates representative of the population with multivariable analysis undertaken for questions with five or more significant univariate variables. RESULTS: 84% stated they would be pleased if their general practitioner (GP) said they did not need antibiotics. Trust in GPs to make antibiotic decisions remains high (89%) and has increased for nurses (76%) and pharmacists (71%). Only 21% would challenge an antibiotic decision; this was significantly greater in BAME participants (OR 2.5; 95% CI 1.89 to 3.35). 70% reported receiving advice when prescribed antibiotics. Belief in benefits of antibiotics for ear infections was very high (68%). Similar to 2017, 81% agreed that antibiotics work for bacterial, 28% cold and influenza viruses. 84% agreed antibiotic resistant bacteria (ARB) are increasing, only 50% agreed healthy people can carry ARB and 39% agreed there was nothing they personally could do about ARB. Social grade DE and BAME participants, and those with less education had significantly less understanding about antibiotics and resistance. CONCLUSIONS: As trust in healthcare practitioners is high, we need to continue antibiotic education and other interventions at GP surgeries and community pharmacies but highlight that most ear infections are not benefitted by antibiotics. Targeted interventions are needed for socioeconomic DE, BAME groups and previous antibiotic users. We need to explore if increasing perceived personal responsibility for preventing ARB reduces antibiotic use.

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.

A Qualitative Investigation of the Acceptability and Feasibility of a Urinary Tract Infection Patient Information Leaflet for Older Adults and Their Carers.

Urinary tract infections (UTIs) can be life threatening in older adults. The aim of this study was to primarily understand the acceptability and feasibility of using a UTI leaflet for older adults in care homes and the community. Qualitative interviews and focus groups informed by the Theoretical Domains Framework were conducted in 2019 with 93 participants from two English areas where a UTI leaflet for older adults had been introduced to improve self-care advice. Discussions were conducted with care staff (carers and nurses), older adults, general practice staff (GPs, nurses and health care assistants), and other relevant stakeholders and covered experiences of using the leaflet; its implementation; and barriers and facilitators to use. Participants deemed the leaflet an acceptable tool. Clinicians and care staff believed that having information in writing would reinforce their messages to older adults. Care staff reported that some older adults may find the information overwhelming. Where implemented, care staff used the leaflet as an educational guide. Clinicians requested the leaflet in electronic and paper formats to suit preferences. Implementation barriers included lack of awareness of the leaflet, lack of staffing and resource, and weak working relationships between care homes and general practices. It is recommended that regional strategies must include plans for dissemination to care homes, training, promotion and easy access to the leaflet. Improvements to the leaflet consisted of inclusion of antibiotic course length, D-mannose, atrophic vaginitis and replacement of less alarmist terminology such as 'life threatening'.

Trends in Antibiotic Prescribing in Out-of-Hours Primary Care in England from January 2016 to June 2020 to Understand Behaviours during the First Wave of COVID-19.

We describe the trend of antibiotic prescribing in out-of-hours (OOH) general practices (GP) before and during England's first wave of the COVID-19 pandemic. We analysed practice-level prescribing records between January 2016 to June 2020 to report the trends for the total prescribing volume, prescribing of broad-spectrum antibiotics and key agents included in the national Quality Premium. We performed a time-series analysis to detect measurable changes in the prescribing volume associated with COVID-19. Before COVID-19, the total prescribing volume and the percentage of broad-spectrum antibiotics continued to decrease in-hours (IH). The prescribing of broad-spectrum antibiotics was higher in OOH (OOH: 10.1%, IH: 8.7%), but a consistent decrease in the trimethoprim-to-nitrofurantoin ratio was observed OOH. The OOH antibiotic prescribing volume diverged from the historical trend in March 2020 and started to decrease by 5088 items per month. Broad-spectrum antibiotic prescribing started to increase in OOH and IH. In OOH, co-amoxiclav and doxycycline peaked in March to May in 2020, which was out of sync with seasonality peaks (Winter) in previous years. While this increase might be explained by the implementation of the national guideline to use co-amoxiclav and doxycycline to manage pneumonia in the community during COVID-19, further investigation is required to see whether the observed reduction in OOH antibiotic prescribing persists and how this reduction might influence antimicrobial resistance and patient outcomes.

Preventing and Managing Urinary Tract Infections: Enhancing the Role of Community Pharmacists-A Mixed Methods Study.

BACKGROUND: Community pharmacists are involved in antimicrobial stewardship through self-care advice and delivering medications for uncomplicated infections. OBJECTIVES: This mixed methods study aimed to identify opportunities to enhance the role of community pharmacists in the management of service users with suspected or confirmed urinary tract infection (UTI). METHODS: Data collection was through a service user survey (n = 51) and pharmacist surveys and semi-structured interviews before (16 interviews, 22 questionnaires) and after (15 interviews, 16 questionnaires) trialing UTI leaflets designed to be shared with service users. Data were analysed inductively using thematic analysis and descriptive tabulation of quantitative data. RESULTS: Twenty-five percent (n = 13/51) of service users with urinary symptoms sought help from a pharmacist first and 65% (n = 33/51) were comfortable discussing their urinary symptoms with a pharmacist in a private space. Community pharmacists were confident as the first professional contact for service users with uncomplicated UTI (n = 13/16, 81%), but indicated the lack of a specific patient referral pathway (n = 16/16, 100%), the need for additional funding and staff (n = 10/16, 62%), and the importance of developing prescription options for pharmacists (5/16, 31%). All community pharmacists reported playing a daily role in controlling antimicrobial resistance by educating service users about viral and bacterial infections and promoting a healthy lifestyle. Enhancing their role will need greater integrated working with general practices and more prescribers based in community pharmacy. CONCLUSION: This study suggests that community pharmacists could play a greater role in the management of uncomplicated UTI. The current reconfiguration of primary care in England with primary care networks and integrated care systems could provide a real opportunity for this collaborative working with potential learning for international initiatives.

How did a Quality Premium financial incentive influence antibiotic prescribing in primary care? Views of Clinical Commissioning Group and general practice professionals.

BACKGROUND: The Quality Premium (QP) was introduced for Clinical Commissioning Groups (CCGs) in England to optimize antibiotic prescribing, but it remains unclear how it was implemented. OBJECTIVES: To understand responses to the QP and how it was perceived to influence antibiotic prescribing. METHODS: Semi-structured telephone interviews were conducted with 22 CCG and 19 general practice professionals. Interviews were analysed thematically. RESULTS: The findings were organized into four categories. (i) Communication: this was perceived as unstructured and infrequent, and CCG professionals were unsure whether they received QP funding. (ii) Implementation: this was influenced by available local resources and competing priorities, with multifaceted and tailored strategies seen as most helpful for engaging general practices. Many antimicrobial stewardship (AMS) strategies were implemented independently from the QP, motivated by quality improvement. (iii) Mechanisms: the QP raised the priority of AMS nationally and locally, and provided prescribing targets to aim for and benchmark against, but money was not seen as reinvested into AMS. (iv) Impact and sustainability: the QP was perceived as successful, but targets were considered challenging for a minority of CCGs and practices due to contextual factors (e.g. deprivation, understaffing). CCG professionals were concerned with potential discontinuation of the QP and prescribing rates levelling off. CONCLUSIONS: CCG and practice professionals expressed positive views of the QP and associated prescribing targets and feedback. The QP helped influence change mainly by raising the priority of AMS and defining change targets rather than providing additional funding. To maximize impact, behavioural mechanisms of financial incentives should be considered pre-implementation.

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.

Infectious Disease and Primary Care Research-What English General Practitioners Say They Need.

BACKGROUND: Infections are one of the most common reasons for patients attending primary care. Antimicrobial resistance (AMR) is perhaps one of the biggest threats to modern medicine; data show that 81% of antibiotics in the UK are prescribed in primary care. AIM: To identify where the perceived gaps in knowledge, skills, guidance and research around infections and antibiotic use lie from the general practitioner (GP) viewpoint. DESIGN AND SETTING: An online questionnaire survey. METHOD: The survey, based on questions asked of Royal College of General Practitioners (RCGP) members in 1999, and covering letter were electronically sent to GPs between May and August 2017 via various primary care dissemination routes. RESULTS: Four hundred and twenty-eight GPs responded. Suspected Infection in the elderly, recurrent urinary tract infection (UTI), surveillance of AMR in the community, leg ulcers, persistent cough and cellulitis all fell into the top six conditions ranked in order of importance that require further research, evidence and guidance. Acute sore throat, otitis media and sinusitis were of lower importance than in 1999. CONCLUSION: This survey will help the NHS, the UK National Institute for Health and Care Excellence (NICE) and researchers to prioritise for the development of guidance and research for chronic conditions highlighted for which there is little evidence base for diagnostic and management guidelines in primary care. In contrast, 20 years of investment into research, guidance and resources for acute respiratory infections have successfully reduced these as priority areas for GPs.