Point prevalence audit surveys of respiratory tract infection consultations and antibiotic prescribing in primary care before and during the COVID-19 pandemic in Ireland.

BACKGROUND: Respiratory tract infections (RTIs) are the most common reason for prescribing antibiotics in general practice. The COVID-19 pandemic has impacted on antibiotic prescribing and delivery of primary care in Ireland. OBJECTIVES: To assess the quality of antibiotic prescribing, the impact of the COVID-19 pandemic and identify opportunities for antimicrobial stewardship (AMS) in Ireland. METHODS: Point prevalence audit surveys for RTI consultations were conducted as part of a European study at three time periods: January-February 2020, March-May 2020 and March-May 2021. Antibiotic prescribing was assessed and comparisons made between the three time periods. RESULTS: In total, 765 consultations were recorded, which were mainly face to face before the pandemic, but changed to predominantly remote consultations during the pandemic surveys in 2020 and 2021 (82% and 75%). Antibiotics were prescribed in 54% of RTI consultations before the pandemic. During pandemic surveys, this dropped to 23% in 2020 and 21% in 2021. There was a decrease in prescribing of Red (reserve) agents in 2021. Assessment against indication-specific quality indicators showed a high proportion of consultations for bronchitis and tonsillitis resulting in an antibiotic prescription (67% and 85%). Point-of-care testing (POCT) to aid diagnosis of RTIs were utilized in less than 1% of consultations. CONCLUSIONS: During the COVID-19 pandemic, there was a reduction in antibiotic prescribing. Opportunities identified to support AMS in primary care in Ireland are targeted initiatives to reduce antibiotic prescribing for bronchitis and tonsillitis and introducing POCT to support appropriate antibiotic prescribing.

Systematic review of topical interventions for the management of odour in patients with chronic or malignant fungating wounds.

Chronic wounds adversely affect the quality of life of individuals and odour is a well-recognised associated factor. Odour can affect sleep, well-being, social interactions, diet and potentially wound healing. This systematic review aims to examine the effectiveness of topical interventions in the management of odour associated with chronic and malignant fungating wounds. A systematic review guided by PRISMA recommendations of randomised controlled trials where odour intensity/odour is the primary outcome was undertaken. Inclusion criteria were adults (18 years and over) with chronic venous, arterial, diabetic or pressure ulcers or with malignant fungating wounds where odour has been managed through topical application of pharmacological/non-pharmacological agents. Searches were conducted in CENTRAL, CINAHL, EMBASE, MEDLINE, Scopus, and Web of Science. Eligibility screening, risk of bias assessment and data extraction was completed by authors working independently. Searches retrieved 171 titles and abstracts (157 post de-duplication). Thirteen studies were retained for full text review of which five (n = 137 individuals) examining the following treatments remained: metronidazole (n = 4), silver (n = 1). Meta-analysis was not possible but individual studies suggest improved outcomes (i.e., reduced odour) using metronidazole. Treatment options to manage wound odour are limited and hampered by lack of clinical trials, small sample sizes, and absence of standardised outcomes and consistent measurement. Whereas metronidazole and silver may have a role in controlling wound odour, robust and well-designed interventions with rigorous procedures and standardised odour outcomes are necessary to evaluate their contribution.

[Assessment of decision-making competence]. / Wilsbekwaamheid beoordelen.

Care providers are frequently confronted with complicated questions about decision-making competence. This article offers tools to help them to deal with those questions. We also look closely at the underlying legal aspects of competence, how and when competence should be assessed, who is responsible for this assessment and which tools are available for this process.

[The role of patient competence in the new Dutch statute concerning involuntary treatment in psychiatry]. / De rol van wilsbekwaamheid in de Wet verplichte geestelijke gezondheidszorg.

BACKGROUND: In the new Compulsory Mental Health Care Act (Wvggz), patient competence has a more central position. AIM: To describe the new position of patient competence in the Wvggz and to reflect on related moral questions. METHOD: Discussion of relevant legal texts and publications. RESULTS: In case of incompetency of a patient, a surrogate decision-maker has to attempt what decision the patient would make if he or she were competent. A new element in the Wvggz is that grandparents and grandchildren can also act as surrogate decision-makers. A competency judgment is mandatory in every decision on involuntary treatment, with the exception of involuntarily commitment. Competent refusal of care has to be respected, unless the patient is in a life threatening situation or there is a risk of other people getting harmed. CONCLUSION: The question is whether the changed position of patient competence in the new law will contribute to the aim of maintaining and enhancing patients' autonomy. Due care in competency judgments is complex and remains important.

[The underrepresentation of complex patient groups in scientific research: ethical considerations]. / De ondervertegenwoordiging van complexe patiëntengroepen in wetenschappelijk onderzoek: ethische overwegingen.

BACKGROUND: Subgroups of patients with severe mental illness are underrepresented in scientific research. One of the possible causes is the fact that in these patient groups barriers may exist to the giving of competent informed consent. AIM: Describing the ethical dilemmas that may occur when conducting research with these patient groups. METHOD: We present an overview of the Dutch legislation and regulation concerning participation in scientific research, and discuss the ethical dilemmas that arise in the mentioned patient groups. We present four directions for solutions. RESULTS: In research with these patient groups more attention is needed for the explicit assessment and enhancement of competence. For the subgroup that is persistently incompetent, the possibilities of doing research with existing patient data without informed consent, need further exploration. CONCLUSION: Further legislative development is needed for research with patients with severe mental illness who are persistently incompetent. Herein, it is crucial to involve ethicists and organizations representing patients' and relatives' perspectives.

Initial impact of a national programme to contain the spread of carbapenemase-producing Enterobacterales in Ireland.

BACKGROUND: Carbapenemase-producing Enterobacterales (CPE) are an emerging cause of healthcare-associated infection (HCAI). In October 2017, a National Public Health Emergency on CPE was declared in Ireland, leading to improved CPE surveillance, implementation of performance monitoring and reporting, and a CPE national expert advisory group. AIM: To evaluate the impact of measures taken to control CPE. METHODS: From August 2017, all acute Health Service Executive (HSE) hospitals were required to report performance indicators related to CPE control (number of CPE tests and number of newly detected CPE). The number of screening samples increased due to this requirement. Monthly incidences were calculated using the overall number of bed-days used (BDU) per hospital. All newly detected CPE were submitted for further genetic identification. Data analysis and predictions were performed for two separate periods (first year and second year after measure implementation). FINDINGS: Over the two-year period studied, the average incidence of CPE cases per 10,000 BDU increased from 1.3 (±0.5) for year 1 to 1.7 (±0.4) for year 2, while the incidence of CPE cases per 1000 screens fell from 3.2 (±0.7) in year 1 to 2.3 (±0.6) in year 2. The OXA-48 gene was most often detected (72%), followed by KPC (13%) and NDM (7%). CONCLUSION: The declaration of the National Public Health Emergency to enhance prevention and control measures for CPE in Ireland is a unique approach in the EU/EEA. Our preliminary results suggest a positive effect on controlling the incidence of CPE in the acute HSE hospital system in Ireland.

Increase in Community Acquired S. aureus Bloodstream Infection Associated with the Sars-Cov-2 Public Health Emergency.

Aim In March 2020, a public health emergency related to COVID-19 was declared in Ireland, resulting in certain healthcare restrictions. We hypothesised, in the microbiology laboratory in Galway University Hospital (GUH), that the national lockdown would impact results from our blood culture service. Methods A surveillance review of all blood cultures received in the microbiology laboratory in GUH for the six-month period March-August 2020 was performed and compared to the same time-period for the preceding four years. Patient demographics and blood culture isolates were collected and reviewed. Results From March to August 2020, 5,753 blood culture sets were tested, of which 6.1% (n=351) were positive; a lower positivity rate than in previous years. In 2020, 46 S. aureus isolates were detected in blood cultures (representing 13.1% of all 351 positive blood cultures), which was significantly higher than 2016-2019. Conclusion The higher number of reported S. aureus bloodstream infections in the SARS-CoV-2-era was unexpected.

The profile of patients with venous leg ulcers: A systematic review and global perspective.

BACKGROUND: A holistic profile that includes demographic, medical history and wound characteristics of individuals with venous leg ulceration is lacking. Lack of such a profile negatively impacts the ability to develop interventions to improve patient outcomes. OBJECTIVES: To describe the profile of the patient population with venous leg ulceration from published observational (non-interventional) studies and to identify gaps in the knowledge base for future research in this area. METHODS: A systematic review of observational studies that included more than 50 patients, from any world region, of any age and in any care setting. RESULTS: twenty studies, involving 3395 patients, from all world regions met our criteria. Demographic characteristics were well reported and showed a female to male ratio of 1.2:1, average age of 47-65 years, high levels of co-morbidities including hypertension (53-71%) and diabetes (16-20%), and only one study reporting ethnicity. When reported, approximately 4-30% had high levels of depression. The average wound size was 18.6-43.39 cm2; mean wound duration was 13.8-65.5 months, mean number of recurrences was four. No study reported on demographic factors plus medical history plus wound characteristics together. CONCLUSION: a comprehensive, holistic profile of the population with VLU is lacking. There is a critical need for more comprehensive profiling to enable the development of targeted interventions to improve outcomes.

[Euthanasia and assisted suicide in psychiatric patients: education needed, also for psychiatrists]. / Euthanasie en hulp bij zelfdoding bij psychiatrische patiënten: onderwijs nodig, ook voor psychiaters.

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Antimicrobial prescribing and infections in long-term care facilities (LTCF): a multilevel analysis of the HALT 2016 study, Ireland, 2017.

BackgroundThe 2016 point prevalence survey (PPS) of healthcare-associated infections (HAI) and antimicrobial use (AMU) in Irish long-term care facilities (LTCF) (HALT) showed a 9.8% AMU and 4.4% HAI prevalence, based on aggregated data analysis.AimOur aim was to identify institutional and resident risk factors of AMU and HAI.MethodsHALT 2016 gathered information using institutional and resident questionnaires, for residents who met the surveillance definition of active HAI and/or AMU, limiting analysis to the aggregated institutional level. In January 2017, we requested additional data on age, sex, urinary catheter use and disorientation of current residents from HALT 2016 LTCF and matched to 2016 HALT data.ResultsOf 224 HALT 2016 LTCF, 80 provided additional information on 3,816 residents; prevalence of AMU was 10.6% and HAI was 4.7%. Presence of a coordinating physician (Odds ratio (OR): 0.3; 95% confidence interval (CI): 0.2-0.6), antimicrobial stewardship committee (OR: 0.2; 95%; CI: 0.1-0.6), healthcare assistants (OR: 0.9; 95% CI: 0.9-1.0), antimicrobial consumption feedback (OR: 0.3; 95% CI: 0.1-0.6) and medical care by personal general practitioner (OR: 0.6; 95% CI: 0.7-1.0) were associated with less AMU and feedback on surveillance of infection prevention and control (IPC) practices (OR: 0.6; 95% CI: 0.3-1.0) with less HAI. AMU and HAI varied significantly between LTCF.ConclusionsMultilevel modelling identified significant inter-facility variation, as well as institutional factors associated with AMU and HAI. An antimicrobial stewardship committee linked with feedback on IPC and prescribing was associated with reduced AMU and HAI.

Adverse events of fluoroquinolones vs. other antimicrobials prescribed in primary care: A systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Fluoroquinolones (FQs) are second-line antimicrobial agents. Once the decision to prescribe an antimicrobial is made, the choice of antimicrobial should be based on both the benefits and adverse effects. This systematic review quantifies the occurrence of common adverse events (AEs) related to FQs in relation to any other antimicrobial for any indication in primary care. METHODS: We searched randomized controlled trials from Embase, PubMed, Cochrane Central Register of Controlled Trials and CINHAL. FQs had to be administered orally, for any indication, to adults and in primary care. Data were extracted independently in standard forms in "Covidence". Pooled estimates of the intervention effects for AEs were determined by the Peto odds ratios (ORs) and 95% confidence intervals (CIs) in Revman. RESULTS: In the 39 studies selected, the most commonly reported AEs were nausea, vomiting, diarrhoea, headache, dizziness, and rash. A meta-analysis of 28 studies reporting AEs showed central nervous system (CNS)-related AEs (OR 1.40 (1.12-1.75) P = 0.003, heterogeneity (I2) = 0%) and gastrointestinal (GI)-related AEs (OR 1.20 (1.06-1.36) P = 0.005, I2 = 80%) were significantly associated with FQs compared with other antimicrobials. Compared with FQs, co-amoxiclav showed significantly more total AEs (OR 0.70 (0.54-0.90) P = 0.006, I2 = 78%) and GI-related AEs (OR 0.69 (0.52-0.91) P = 0.008, I2 = 94%). Withdrawal or discontinuation due to drug-related AEs was higher for FQs (OR 1.19 (1.00-1.42) P = 0.05, I2 = 5%). Sensitivity analyses did not change these results. CONCLUSION: FQs are associated with more CNS- and GI-related AEs compared with other types of antimicrobial. This information is relevant to support decision making in relation to antimicrobial prescribing.

Geographic distribution and incidence of Lyme borreliosis in the west of Ireland.

BACKGROUND: Lyme borreliosis is caused by Borrelia burgdorferi and is the most common tick-transmitted infection in temperate regions. Infection often presents with erythema migrans and/or other clinical features in early infection. METHODS: Blood samples are submitted for testing for antibodies to Borrelia burgdorferi by enzyme immunoassay and positive samples are confirmed by a reference laboratory by IgG and IgM line immune assay. A retrospective extraction of all laboratory requests and results for Lyme borreliosis from 2011 to 2014 was performed. Patient addresses were mapped to local electoral area (LEA). RESULTS: The total number of requests was 5049 and 242 (5%) were positive over 5 years. The number of positive and tested samples were 40/748, 45/905, 41/947, 73/1126 and 43/1323 from 2011 to 2014. Even though the number of requests increased over the years, there was no significant increase in the number of positives. Incidences per 100,000 population for requests and positives were calculated at LEA level and showed considerable variation. The highest incidence was shown in one LEA (Connemara) with nearly 500 requests and 43 positives per 100,000 population per year. CONCLUSIONS: Increased awareness may explain the increase in requests. There is no indication of an increase in incidence. As many GPs treat suspected Lyme borreliosis empirically without testing and as antibody may be undetectable early in the course of illness, the true incidence of infection is likely to exceed the number of laboratory-confirmed cases.

Targeted de-escalation rounds may effectively and safely reduce meropenem use.

OBJECTIVE: Use of meropenem in our hospital has doubled in recent years. An audit in 2013 showed that although initiation of therapy with meropenem was generally appropriate, therapy was rarely subsequently reviewed and de-escalated where appropriate. Therefore, a structured stewardship initiative focussed on meropenem de-escalation was developed. METHODS: A local guideline for review and de-escalation of meropenem was developed and approved by the Antimicrobial Stewardship Team. The guideline outlined clinical and microbiological criteria which when met should lead to recommendation for meropenem de-escalation. Implementation of the guideline was piloted for a period of 4 weeks by a consultant microbiologist and an antimicrobial pharmacist. Days of meropenem use and crude mortality in those in whom de-escalation was implemented were compared with those where de-escalation was not recommended or was recommended but not implemented. RESULTS: Thirty-three patients were reviewed. Overall, a recommendation to de-escalate from meropenem to a specified alternative antibiotic was made for 18 (55 %) patients. This advice was followed for 12 (36 %) patients. The median days of meropenem use in patients where meropenem was de-escalated was 4.5 days (range 2-19) compared with 14 days (range 6-84) where de-escalation was not recommended or the recommendation was not implemented. There was no statistically significant difference in crude mortality between patients de-escalated from meropenem and those where meropenem was continued. CONCLUSION: This pilot study suggests that targeted carbapenem de-escalation stewardship activity based on pre-determined criteria, while labour intensive, can effectively and safely reduce meropenem use in the acute hospital setting.

[Moral case deliberation: time for ethical reflection in the daily practice of mental health care]. / Moreel beraad: tijd voor ethische reflectie in de dagelijkse praktijk van de ggz.

BACKGROUND: Nowadays, reflecting on ethics, which we choose to call moral case deliberation, is occurring more and more frequently in psychiatric institutions. We have personal experience of organising and supervising moral case deliberation in a large psychiatric institute and we can confirm the positive effects of moral case deliberation which have been reported in the literature. AIM: To describe a structured method for moral case deliberation which enables care-givers in health care and/or addiction care to reflect on moral dilemmas. METHOD: We refer to the main findings in relevant literature and describe how we developed a structured method for implementing moral case deliberation. RESULTS: Our studies of the literature indicate that systematic reflection about ethical dilemmas can improve the quality of care and make care-givers more satisfied with their work. This is why we have developed our own method which is applicable particularly to psychiatric and/or addition care and which can be used systematically in discussions of moral dilemmas. CONCLUSION: Our method for discussing ethical issues works well in clinical practice, particularly when it is embedded in a multidisciplinary context. Of course, to ensure the continuity of the system, deliberation about moral and ethical issues needs to be financially safeguarded and embedded in the organisation. Discussion of moral issues improves the quality of care and increases care-givers' satisfaction with their work.

Six-year follow-up of the SPHERE RCT: secondary prevention of heart disease in general practice.

OBJECTIVE: To determine the long-term effectiveness of a complex intervention in primary care aimed at improving outcomes for patients with coronary heart disease. DESIGN: A 6-year follow-up of a cluster randomised controlled trial, which found after 18 months that both total and cardiovascular hospital admissions were significantly reduced in intervention practices (8% absolute reduction). SETTING: 48 general practices in the Republic of Ireland and Northern Ireland. PARTICIPANTS: 903 patients with established coronary heart disease at baseline in the original trial. INTERVENTION: The original intervention consisted of tailored practice and patient plans; training sessions for practitioners in medication prescribing and behavioural change; and regular patient recall system. Control practices provided usual care. Following the intervention period, all supports from the research team to intervention practices ceased. PRIMARY OUTCOME: hospital admissions, all cause and cardiovascular; secondary outcomes: mortality; blood pressure and cholesterol control. RESULTS: At 6-year follow-up, data were collected from practice records of 696 patients (77%). For those who had died, we censored their data at the point of death and cause of death was established. There were no significant differences between the intervention and control practices in either total (OR 0.83 (95% CI 0.54 to 1.28)) or cardiovascular hospital admissions (OR 0.91 (95% CI 0.49 to 1.65)). We confirmed mortality status of 886 of the original 903 patients (98%). There were no significant differences in mortality (15% in intervention and 16% in control) or in the proportions of patients above target control for systolic blood pressure or total cholesterol. CONCLUSIONS: Initial significant differences in the numbers of total and cardiovascular hospital admissions were not maintained at 6 years and no differences were found in mortality or blood pressure and cholesterol control. Policymakers need to continue to assess the effectiveness of previously efficacious programmes. TRIAL REGISTRATION NUMBER: Current Controlled Trials ISRCTN24081411.

Urban and rural differences in out-of-hospital cardiac arrest in Ireland.

BACKGROUND: More than a third of Ireland's population lives in a rural area, defined as the population residing in all areas outside clusters of 1500 or more inhabitants. This presents a challenge for the provision of effective pre-hospital resuscitation services. In 2012, Ireland became one of three European countries with nationwide Out-of-Hospital Cardiac Arrest (OHCA) register coverage. An OHCA register provides an ability to monitor quality and equity of access to life-saving services in Irish communities. AIM: To use the first year of national OHCAR data to assess differences in the occurrence, incidence and outcomes of OHCA where resuscitation is attempted and the incident is attended by statutory Emergency Medical Services between rural and urban settings. METHODS: The geographical coordinates of incident locations were identified and co-ordinates were then classified as 'urban' or 'rural' according to the Irish Central Statistics Office (CSO) definition. RESULTS: 1798 OHCA incidents were recorded which were attended by statutory Emergency Medical Services (EMS) and where resuscitation was attempted. There was a higher percentage of male patients in rural settings (71% vs. 65%; p = 0.009) but the incidence of male patients did not differ significantly between urban and rural settings (26 vs. 25 males/100,000 population/year p = 0.353). A higher proportion of rural patients received bystander cardiopulmonary resuscitation (B-CPR) 70% vs. 55% (p ≤ 0.001), and had defibrillation attempted before statutory EMS arrival (7% vs. 4% (p = 0.019), respectively). Urban patients were more likely to receive a statutory EMS response in 8 min or less (33% vs. 9%; p ≤ 0.001). Urban patients were also more likely to be discharged alive from hospital (6% vs. 3%; p = 0.006) (incidence 2.5 vs. 1.1/100,000 population/year; p ≤ 0.001). Multivariable analysis of survival showed that the main variable of interest i.e. urban vs. rural setting was also independently associated with discharge from hospital alive (OR 3.23 (95% CI 1.43-7.31)). CONCLUSION: There are significant disparities in the incidence of resuscitation attempts in urban and rural areas. There are challenges in the provision of services and subsequent outcomes from OHCA that occur outside of urban areas requiring novel and innovative solutions. An integrated community response system is necessary to improve metrics around OHCA response and outcomes in rural areas.