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  • Journal article
    Rawson TM, Moore LSP, Gilchrist MJ, Holmes AHet al., 2015,

    Antimicrobial stewardship: are we failing in cross-specialty clinical engagement?

    , Journal of Antimicrobial Chemotherapy, Vol: 71, Pages: 554-559, ISSN: 1460-2091

    Background Antimicrobial resistance (AMR) is a public health priority and leading patient safety issue. Globally, antimicrobial stewardship (AMS) has been integral in promoting therapeutic optimization whilst minimizing harmful antimicrobial use. A cross-sectional, observational study was undertaken to investigate the coverage of AMS and antibacterial resistance across clinical scientific conferences in 2014, as a surrogate marker for current awareness and attributed importance.Methods Clinical specialties were identified, and the largest corresponding clinical scientific/research conferences in 2014 determined (i) within the UK and (ii) internationally. Conference characteristics and abstracts were interrogated and analysed to determine those related to AMS and AMR. Inter-specialty variation was assessed using χ2 or Fisher's exact statistical analysis.Results In total, 45 conferences from 23 specialties were analysed representing 59 682 accepted abstracts. The UK had a significantly greater proportion of AMS-AMR-related abstracts compared with international conferences [2.8% (n = 221/7843) compared with 1.8% (n = 942/51 839); P < 0.001]. Infection conferences contained the greatest proportion of AMS-AMR abstracts, representing 20% (732/3669) of all abstracts [UK 66% (80/121) and international 18% (652/3548); P < 0.0001]. AMS-AMR coverage across all general specialties was poor [intensive care 9% (116/1287), surgical 1% (8/757) and medical specialties 0.64% (332/51 497)] despite high usage of antimicrobials across all.Conclusions Despite current AMS-AMR strategies being advocated by infection specialists and discussed by national and international policy makers, AMS-AMR coverage remained limited across clinical specialty scientific conferences in 2014. We call for further intervention to ensure specialty engagement with AMS programmes and promote the AMR agenda across clinical practice.
  • Journal article
    Birgand GJC, Bourigault C, Moore L, Vella V, Lepelletier D, Holmes A, Iucet JCet al., 2015,

    Measures to eradicate multidrug-resistant organism outbreaks: How much does it cost?

    , Clinical Microbiology and Infection, Vol: 22, Pages: 162.e1-162.e9, ISSN: 1469-0691

    This study aimed to assess the economic burden of infection control measures that succeeded in eradicating multidrug resistant organisms (MDROs) in emerging epidemic contexts in hospital settings. Medline, Embase and Ovid databases were systematically interrogated for original English language articles detailing costs associated with strict measures to eradicate MDROs published between 1st January 1974 and 2nd November 2014. This study was conducted in accordance with the PRISMA guidelines. Overall, 13 original articles were retrieved reporting data on several MDROs including; glycopeptide resistant enterococci (n=5), carbapenemase producing Enterobacteriacae (n=1), meticillin resistant Staphylococcus aureus (n=5) and carbapenem-resistant Acinetobacter baumannii (n=2). Overall, the cost of strict measures to eradicate MDROs ranged from €285 to €57,532 per positive patient. The major component of these overall costs was related to interruption of new admissions, representing from €2,466 to €47,093 per positive patient (69% of the overall cost in mean, range: 13 - 100), followed by mean laboratory costs of €628 to €5,849 (24%, range: 3.3 - 56.7), staff reinforcement €6,204 to €148,381 (22%, range: 3.3 – 52) and contact precautions €166 to €10,438 per positive patient (18%, range: 0.7 - 43.3). Published data on the economic burden of strict measures to eradicate MDRO are limited, heterogeneous, and weakened by several methodological flaws. Novel economic studies should be performed to assess the financial impact of current policies and identify the most cost-effective strategies to eradicate emerging MDROs in healthcare facilities.
  • Journal article
    Venanzio V, Gharbi M, Moore LSP, Robotham J, Davies F, Brannigan E, Galletly T, Holmes AHet al., 2015,

    Screening suspected cases for carbapenemase-producing Enterobacteriaceae, inclusion criteria and demand

    , JOURNAL OF INFECTION, Vol: 71, Pages: 493-495, ISSN: 0163-4453
  • Journal article
    Powell N, Franklin BD, Jacklin A, Wilcock Met al., 2015,

    Omitted doses as an unintended consequence of a hospital restricted antibacterial system: a retrospective observational study

    , Journal of Antimicrobial Chemotherapy, Vol: 70, Pages: 3379-3383, ISSN: 1460-2091

    Objective: To determine the frequency of omitted doses of antibacterial agents and explore a number of risk factors, including the effect of a restricted antibacterial system. Methods: Antibacterial data were extracted from a hospital electronic prescribing and medication administration system for the period 1 January to 30 April 2014. Percentage dose omission rates were calculated. Omission rates for the first dose of antibacterial courses were analysed using logistic regression to identify any correlation between first dose omission rates and potential risk factors including the antibacterials’ restriction status and whether or not they were ward stock. Results: 90,761 antibacterial doses were included. Of these, 6,535 (7.2%) were documented as having been omitted; 847 (0.9% of 90,761) due to medication being unavailable. Non-restricted, ward stock antibacterials had the lowest frequency of omission with 6.2% (271 of 4,391) first doses omitted. The prevalence was 10.4% (27 of 260) for restricted, ward stock antibacterials (OR = 1.6, 95% CI: 1.0 – 2.4, p = 0.027), and 15.5% (53 of 341) for non-restricted, non-ward stock antibacterials (OR = 2.7, 95% CI: 2.0 – 3.7, p = <0.001). Restricted, non-ward stock antibacterials had the highest frequency of 30.7% (71 of 231; OR = 6.2, 95% CI: 4.5 to 8.4, p = <0.001). Conclusions: Antibacterials not stocked in clinical areas were significantly more likely to be omitted. The prevalence of omitted doses increased further if the antibiotic was also restricted. To achieve safe effective antimicrobial use, a balance is needed between promoting antimicrobial stewardship and preventing unintended omitted doses.
  • Journal article
    Charani E, Gharbi M, Frost G, Drumright L, Holmes Aet al., 2015,

    Antimicrobial therapy in obesity: a multicentre cross-sectional study.

    , Journal of Antimicrobial Chemotherapy, Vol: 70, Pages: 2906-2912, ISSN: 1460-2091

    Objectives Evidence indicates a relationship between obesity and infection. We assessed the prevalence of obesity in hospitalized patients and evaluated its impact on antimicrobial management.Methods Three National Health Service hospitals in London in 2011–12 were included in a cross-sectional study. Data from all adult admissions units and medical and surgical wards were collected. Patient data were collected from the medication charts and nursing and medical notes. Antimicrobial therapy was defined as ‘complicated’ if the patient's therapy met two or more of the following criteria: (i) second- or third-line therapy according to local policy; (ii) intravenous therapy where an alternative oral therapy was appropriate; (iii) longer than the recommended duration of therapy as per local policy recommendations; (iv) repeated courses of therapy to treat the same infection; and (v) specialist advice on antimicrobial therapy provided by the medical microbiology or infectious diseases teams.Results Of the 1014 patients included in this study, 22% (225) were obese, 69% (696) were normal/overweight and 9% (93) were underweight. Obese patients were significantly more likely to have more complicated antimicrobial therapy than normal/overweight and underweight patients (36% versus 19% and 23%, respectively, P = 0.002). After adjustment for hospital, age group, comorbidities and the type of infection, obese patients remained at significantly increased odds of receiving complicated antimicrobial therapy compared with normal/overweight patients (OR = 2.01, 95% CI 1.75–3.45).Conclusions One in five hospitalized patients is obese. Compared with the underweight and normal/overweight, the antimicrobial management in the obese is significantly more complicated.
  • Journal article
    Castro Sanchez EM, Spanoudakis E, Holmes A, 2015,

    Readability of Ebola information on websites of public health agencies, United States, United Kingdom, Canada, Australia, and Europe

    , Emerging Infectious Diseases, Vol: 21, ISSN: 1080-6059

    Public involvement in efforts to control the current Ebola virus disease epidemic requires understandable information. We reviewed the readability of Ebola information from public health agencies in non–Ebola-affected areas. A substantial proportion of citizens would have difficulty understanding existing information, which would potentially hinder effective health-seeking behaviors.
  • Journal article
    Shah N, Castro-Sanchez E, Charani E, Drumright LN, Holmes AHet al., 2015,

    Towards changing healthcare workers' behaviour: a qualitative study exploring non-compliance through appraisals of infection prevention and control practices

    , JOURNAL OF HOSPITAL INFECTION, Vol: 90, Pages: 126-134, ISSN: 0195-6701
  • Journal article
    Reynolds M, Larsson E, Hewitt R, Garfield S, Franklin BDet al., 2015,

    Development and evaluation of a pocket card to support prescribing by junior doctors in an English hospital.

    , International Journal of Clinical Pharmacy, Vol: 37, Pages: 762-766, ISSN: 2210-7711

    Background Junior doctors do most inpatient prescribing, with a relatively high error rate, and locally had reported finding prescribing very stressful. Objective To develop an intervention to improve Foundation Year 1 (FY1) doctors' experience of prescribing, and evaluate their satisfaction with the intervention and perceptions of its impact. Methods Based on findings of a focus group and questionnaire, we developed a pocket Dose Reference Card ("Dr-Card") for use at the point of prescribing. This summarised common drugs and dosing schedules and was distributed to all new FY1 doctors in a London teaching trust. A post-intervention questionnaire explored satisfaction and perceived impact. Results Focus group participants (n = 12) described feeling anxious and time pressured when prescribing; a quick reference resource for commonly prescribed drug doses was suggested. Responses to the exploratory questionnaire reinforced these findings. Following Dr-Card distribution, the post-intervention questionnaire revealed that 29/38 (76 %) doctors were still using it 2 months after distribution and 38/38 (100 %) would recommend ongoing production. Conclusions FY1 doctors reported feeling stressed and time pressured when prescribing; this was perceived to contribute to error. A pocket card presenting common drugs and doses was well-received, perceived to be useful, and recommended for on-going use.
  • Journal article
    Gharbi M, Moore LSP, Gilchrist M, Thomas CP, Bamford K, Brannigan ET, Holmes AHet al., 2015,

    Forecasting carbapenem resistance from antimicrobial consumption surveillance: Lessons learnt from an OXA-48-producing Klebsiella pneumoniae outbreak in a West London renal unit

    , International Journal of Antimicrobial Agents, Vol: 46, Pages: 150-156, ISSN: 1872-7913

    This study aimed to forecast the incidence rate of carbapenem resistance and to assess the impact of an antimicrobial stewardship intervention using routine antimicrobial consumption surveillance data. Following an outbreak of OXA-48-producing Klebsiella pneumoniae (January 2008–April 2010) in a renal cohort in London, a forecasting ARIMA model was derived using meropenem consumption data [defined daily dose per 100 occupied bed-days (DDD/100 OBD)] from 2005–2014 as a predictor of the incidence rate of OXA-48-producing organisms (number of new cases/year/100,000 OBD). Interrupted times series assessed the impact of meropenem consumption restriction as part of the outbreak control. Meropenem consumption at lag −1 year (the preceding year), highly correlated with the incidence of OXA-48-producing organisms (r = 0.71; P = 0.005), was included as a predictor within the forecasting model. The number of cases/100,000 OBD for 2014–2015 was estimated to be 4.96 (95% CI 2.53–7.39). Analysis of meropenem consumption pre- and post-intervention demonstrated an increase of 7.12 DDD/100 OBD/year (95% CI 2.97–11.27; P < 0.001) in the 4 years preceding the intervention, but a decrease thereafter. The change in slope was −9.11 DDD/100 OBD/year (95% CI −13.82 to −4.39). Analysis of alternative antimicrobials showed a significant increase in amikacin consumption post-intervention from 0.54 to 3.41 DDD/100 OBD/year (slope +0.72, 95% CI 0.29–1.15; P = 0.01). Total antimicrobials significantly decreased from 176.21 to 126.24 DDD/100 OBD/year (P = 0.05). Surveillance of routinely collected antimicrobial consumption data may provide a key warning indicator to anticipate increased incidence of carbapenem-resistant organisms. Further validation using real-time data is needed.
  • Journal article
    Charani E, Gharbi M, Hickson M, Othman S, Alfituri A, Frost G, Holmes Aet al., 2015,

    Lack of weight recording in patients being administered narrow therapeutic index antibiotics: a prospective cross-sectional study

    , BMJ Open, Vol: 5, ISSN: 2044-6055

    Objectives Patient weight is a key measure for safe medication management and monitoring of patients. Here we report the recording of patient's body weight on admission in three hospitals in West London and its relationship with the prescription of antibiotic drugs where it is essential to have the body weight of the patient.Methods A prospective cross-sectional study was conducted in three teaching hospitals in West London. Data were collected during March 2011–September 2011 and July 2012–August 2012, from adult admissions units, medical and surgical wards. Data from each ward were collected on a single day to provide a point prevalence data on weight recording. Patient medication charts, nursing and medical notes were reviewed for evidence of weight and height recording together with all the medication prescribed for the patients. An observational study collecting data on the weight recording process was conducted on two randomly selected wards to add context to the data.Results Data were collected on 1012 patients. Weight was not recorded for 46% (474) of patients. Eighty-nine patients were prescribed a narrow therapeutic antibiotic, in 39% (35/89) of these weight was not recorded for the patient. Intravenous vancomycin was the most commonly prescribed antibiotic requiring therapeutic monitoring. In total 61 patients were receiving intravenous vancomycin and of these 44% (27/61) did not have their weight recorded. In the observational study, the most frequently identified barrier to weight not being recorded was interruptions to the admission process.Conclusions Despite the clinical importance of body weight measurement it is poorly recorded in hospitalised patients, due to interruptions to the workflow and heavy staff workloads. In antibiotics a correct, recent patient weight is required for accurate dosing and to keep drugs within the narrow therapeutic index, to ensure efficacy of prescribing and reduce toxicity.

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