A hidden gem in multidisciplinary antimicrobial stewardship: a systematic review on bedside nurses' activities in daily practice regarding antibiotic use.

Background: Antimicrobial stewardship (AMS), the set of actions to ensure antibiotics are used appropriately, is increasingly targeted at all those involved in the antimicrobial pathway, including nurses. Several healthcare organizations have issued position statements on how bedside nurses can be involved in AMS. However, it remains unclear how nurses, in reality, contribute to appropriate antibiotic use. Objectives: To systematically search the literature to describe the activities bedside nurses perform regarding antibiotic use in daily clinical practice, in relation to the activities proposed by the aforementioned position statements. Methods: We searched MEDLINE, Embase, CINAHL and grey literature until March 2021. Studies were included if they described activities regarding antibiotic use performed by bedside nurses. Methodological rigour was assessed by applying the Mixed Method Appraisal Tool. Results: A total of 118 studies were included. The majority of the proposed nurses' activities were found in daily practice, categorized into assessment of clinical status, collection of specimens, management of antimicrobial medication, prompting review and educating patient and relatives. Nurses may take the lead in these clinical processes and are communicators in all aspects of the antimicrobial pathway. Patient advocacy appears to be a strong driver of bedside nurses' activities. Conclusions: Nurses' activities are already integrated in the day-to-day nursing practice and are grounded in the essence of nursing, being a patient advocate and showing nursing leadership in safeguarding the antimicrobial treatment process. An essential element of the nursing role is communication with other stakeholders in the patient-centred antimicrobial pathway. Educating, engaging and empowering nurses in this already integrated role, could lead to a solid, impactful nursing contribution to AMS.

Nurse Leadership and Work Environment Association with Outcome Expectancy and Self-Efficacy in Evidence-Based Practice among Hospital Nurses in The Netherlands: A Cross-Sectional Study.

The active participation of nurses in evidence-based practice (EBP) is challenging and topical, as shown by the worldwide calls for appropriate, accessible, affordable care and the de-implementation of unnecessary care. Nurses' perceived support from their managers and work environments may affect their self-efficacy and outcome expectancy in EBP, as well as hinder them in EBP. Associations between these issues have not yet been explored. This study examines the association of self-efficacy and outcome expectancy levels in EBP, as well as the perceived support for EBP from nurse leaders and in the working environment, among Dutch hospital nurses. METHODS: Questionnaires measuring nurses' self-efficacy, outcome expectancy, and perceived support for EBP from nurse leaders and their work environment were completed by 306 nurses in eight hospitals between March 2021 and June 2021. We used multilevel regression analyses to determine the associations and covariates. RESULTS: This study shows that EBP-supportive leaders and work environments positively contribute to nurses' self-efficacy and outcome expectancy in EBP, along with the covariates undertaking EBP activities and educational level. CONCLUSIONS: To improve nurses' active participation in EBP, nurses need to increase their self-efficacy and outcome expectancy in EBP. Supportive leaders and a supportive work environment do have an impact. Hence, these factors need attention when implementing EBP among nurses.

Three-Questions-Method for Coping with the Emotional Burden of Nurses and Nursing Students during COVID-19.

BACKGROUND: Nurses and nursing students experienced an emotional burden while working during the COVID-19 outbreak. During the COVID-19 outbreak three questions for nurses working under these extreme circumstances were formulated: 1. What today's events do you remember? 2. How do you feel (physically and mentally)? 3. Do you have enough support? The purpose of this study was to obtain insight into whether nurses and nursing students perceive that the use of the three-questions-method contributes to effective coping with the emotional burden during the COVID-19 outbreak. METHODS: Focus group interviews were held with hospital nurses (n = 11) and nursing students with internships in mental health care (n = 2), hospital (n = 9), and homecare/nursing home care (n = 3) in September 2020 followed by twenty semi-structured interviews one year later. RESULTS: Almost all nurses and nursing students named factors that contributed to the emotional burden: fear, powerlessness, frustration, lack of knowledge about COVID-19, and pressure to pass the internship. Participants indicated that using the three-questions-method can help to effectively cope with the emotional burden during and after the COVID-19 outbreak. CONCLUSIONS: Using the three-questions-method offers added value in coping with emotional burden and can be used in education as well as in practice.

Sensitisation patterns and association with age, gender, and clinical symptoms in children with allergic rhinitis in primary care: a cross-sectional study.

BACKGROUND: Polysensitisation is a frequent phenomenon in patients with allergic rhinitis. However, few studies have investigated the characteristics of polysensitised children, especially in primary care. OBJECTIVES: This analysis describes the patterns of sensitisation to common allergens and the association with age, gender, and clinical symptoms in children in primary care diagnosed with allergic rhinitis. METHODS: Cross-sectional data from two randomised double-blind placebo-controlled studies were used to select children aged 6-18 years (n=784) with a doctor's diagnosis of allergic rhinitis or use of relevant medication for allergic rhinitis in primary care. They were assessed for age, gender, specific IgE (type and number of sensitisations), nasal and eye symptom scores. RESULTS: In 699 of the 784 children (89%) with a doctor's diagnosis or relevant medication use, a positive IgE test for one or more allergens was found. Polysensitisation (>2 sensitisations) was found in 69% of all children. Sensitisation was more common in children aged 9-13 than in younger children aged 5-8 years (p=0.03). Monosensitisation and polysensitisation were not significantly different in girls and boys. The severity of clinical symptoms did not differ between polysensitised and monosensitised children, but symptoms were significantly lower in non-sensitised children. CONCLUSIONS: Polysensitisation to multiple allergens occurs frequently in children with allergic rhinitis in general practice. Overall, clinical symptoms are equally severe in polysensitised and monosensitised children. Treatment decisions for allergic rhinitis should be made on the basis of a clinical history and allergy testing.

Exhaled nitric oxide measures allergy not symptoms in children with allergic rhinitis in primary care: a prospective cross-sectional and longitudinal cohort study.

BACKGROUND: Allergic rhinitis (AR) and asthma are both inflammatory diseases and are often associated. Relationships between fractional exhaled nitric oxide (FeNO) and asthma, atopy, and quality of life have been shown. AIMS: This study aimed to determine whether FeNO in children with AR (n=158) or combined AR and asthma (n=93) was associated with clinical symptoms, house dust mite (HDM)-specific IgE, and rhinitis-specific quality of life, both cross-sectionally and longitudinally. METHODS: Children with AR aged 6-18 years (n=251) in primary care were assessed for FeNO, nasal symptom scores, asthma symptom scores, quality of life, and HDM-specific IgE at baseline and 2 years later. RESULTS: We found similarly elevated FeNO in children with only AR and in those with combined AR and asthma. No correlations were found between FeNO and nasal or asthma symptoms and rhinitis-related quality of life. Longitudinal correlations were strongest for HDM-specific IgE (r=0.91, p<0.0001). CONCLUSIONS: FeNO was similar in a selected group of children with AR with and without asthma in primary care and was unrelated to symptoms or quality of life in both groups. FeNO is unlikely to be a useful biomarker of the clinical severity of upper or lower airway disease in primary care.

Sublingual immunotherapy not effective in house dust mite-allergic children in primary care.

BACKGROUND: Sublingual immunotherapy (SLIT) as a therapy for the treatment of allergic rhinitis in children might be acceptable as an alternative for subcutaneous immunotherapy. However, the efficacy of SLIT with house dust mite extract is not well established. OBJECTIVE: To investigate whether SLIT in house dust mite-allergic children recruited in primary care is effective and safe. METHODS: Children aged 6-18 years (n = 251) recruited in primary care with a house dust mite-induced allergic rhinitis received either SLIT or placebo for 2 years. Symptoms and medication use were assessed throughout the study. Primary outcome parameter was the mean total nose symptom score (scales 0-12) during the autumn of the second treatment year. Safety was assessed by recording any adverse event. RESULTS: Overall, the mean nose symptom score ± s.d. after 2 years of treatment showed no significant effect of SLIT (symptom score intervention group 2.26 ± 1.84 vs. placebo group, 2.02 ± 1.67; p = 0.08). There were no significant differences in secondary outcomes, nor in subgroup analyses. The number of patients reporting adverse events was comparable between both groups. CONCLUSIONS: Sublingual immunotherapy with house dust mite allergen was not better than placebo in reducing rhinitis symptoms in house dust mite-allergic children in primary care. SLIT as administered in this study can be considered safe.

Sublingual immunotherapy in children with allergic rhinitis: quality of systematic reviews.

Systematic reviews have gained popularity as a way to combine the increasing amount of research information. This study assessed the quality of systematic reviews and meta-analyses of sublingual immunotherapy (SLIT) for allergic rhinitis in children, published since 2000. Eligible reviews were identified by searching Medline/Pubmed, Embase, and the Cochrane Library, from 2000 through 2008. Methodological quality was assessed using the assessment of multiple systematic reviews instrument. Ten systematic reviews were included, one of which was published in the Cochrane Library. Eight reviews gave some details about the search strategy. None of the reviews included measures to avoid selection bias. In 60% of the reviews, the methodological quality of the included studies was (partly) assessed. Four reviews pooled the results of individual studies, neglecting clinical heterogeneity. Three of the 10 reviews provided information about sources of funding or grants from industry. Of the 10 reviews, the six reviews with the highest overall score scored 5-8 points, indicating moderate quality. Systematic reviews are useful to evaluate the efficacy of SLIT in children. Although more reviews have become available, the methodological quality could be improved. SLIT for children could be promising, but methodological flaws in the reviews and individual studies are too serious to draw definite conclusions.

Allergic rhinitis in children: incidence and treatment in Dutch general practice in 1987 and 2001.

Allergic rhinitis is a common chronic disorder in children, mostly diagnosed in primary health care. This study investigated the national incidence and treatment of allergic rhinitis among children aged 0-17 yr in Dutch general practice in 1987 and 2001 to establish whether changes have occurred. A comparison was made with data from the first (1987) and second (2001) Dutch national surveys of general practice on children aged 0-17 yr. Incidence rates were compared by age, sex, level of urbanization and season. The management of the general practitioner was assessed regarding drug prescriptions and referrals to medical specialists, and compared with the clinical guideline issued in 1996. The incidence rate of allergic rhinitis increased from 6.6 (1987) to 9.2 (2001) per 1000 person-years. We found a male predominance with a switch in adolescence to a female predominance at both time points. The increase in incidence was the highest in rural (<30,000 inhabitants) and suburban areas (30,000-50,000 inhabitants). Compared to 1987, there was a significant increase in incidence in the central part of the Netherlands in 2001. In both years, the incidence was higher in spring compared with the other seasons. In 2001, children of natives and western immigrants visited the general practitioner more often with complaints of allergic rhinitis compared to 1987. In 1987, prescribed medication consisted mainly of nasal corticosteroids (36%) and in 2001 of oral antihistamines (45%). Although a clinical guideline was not issued until 1996, overall, the treatment of allergic rhinitis by general practitioners was in both years in accordance with the current clinical guideline, but with a stronger adherence in 2001. The results show an increased incidence in the past decades of allergic rhinitis in children in Dutch general practice. The shift to a smaller spectrum of prescriptions in 2001 may be a result of the 1996 clinical guideline.

Randomized double-blind placebo-controlled trial of sublingual immunotherapy in children with house dust mite allergy in primary care: study design and recruitment.

BACKGROUND: For respiratory allergic disorders in children, sublingual immunotherapy has been developed as an alternative to subcutaneous immunotherapy. Sublingual immunotherapy is more convenient, has a good safety profile and might be an attractive option for use in primary care. A randomized double-blind placebo-controlled study was designed to establish the efficacy of sublingual immunotherapy with house dust mite allergen compared to placebo treatment in 6 to 18-year-old children with allergic rhinitis and a proven house dust mite allergy in primary care. Described here are the methodology, recruitment phases, and main characteristics of the recruited children. METHODS: Recruitment took place in September to December of 2005 and 2006. General practitioners (in south-west Netherlands) selected children who had ever been diagnosed with allergic rhinitis. Children and parents could respond to a postal invitation. Children who responded positively were screened by telephone using a nasal symptom score. After this screening, an inclusion visit took place during which a blood sample was taken for the RAST test. RESULTS: A total of 226 general practitioners invited almost 6000 children: of these, 51% was male and 40% <12 years of age. The target sample size was 256 children; 251 patients were finally included. The most frequent reasons given for not participating were: absence or mildness of symptoms, absence of house dust mite allergy, and being allergic to grass pollen or tree pollen only. Asthma symptoms were reported by 37% of the children. Of the enrolled children, 71% was sensitized to both house dust mite and grass pollen. Roughly similar proportions of children were diagnosed as being sensitized to one, two, three or four common inhalant allergens. CONCLUSION: Our study was designed in accordance with recent recommendations for research on establishing the efficacy of sublingual immunotherapy; 98% of the target sample size was achieved. This study is expected to provide useful information on sublingual immunotherapy with house dust mite allergen in primary care. The results on efficacy and safety are expected to be available by 2010. TRIAL REGISTRATION: the trial is registered as ISRCTN91141483 (Dutch Trial Register).