Where to start? The Irish Emergency Department Antimicrobial Discharge (EDAD) study: a multicentre, prospective cohort analysis.

Objectives: To determine the percentage of patients across Ireland who are discharged from the Emergency Department (ED) with an antimicrobial prescription, the indication, classification of infections, and guideline compliance. To identify potential areas for antimicrobial stewardship (AMS) interventions in the ED. Patients and methods: A multicentre, prospective cohort analysis study in EDs across eight hospitals in Ireland. At each site, patients aged 1 month and older who presented to the ED and were discharged directly from the ED were included. A random selection of records of patients discharged from the ED were reviewed until a minimum of 30 records with an infection diagnosis resulting in an antibiotic prescription were obtained per hospital. The number of patient discharges with no antibiotic prescriptions were included to calculate the denominator. The indication, infection classification and guideline compliance data were collected on the 30 prescriptions in the participating hospitals. Results: A total of 2619 patient records were reviewed. Of these, 249 (9.5%) patients were discharged with antimicrobial prescriptions from the ED. Most (158; 63%) were classified as probable bacterial infection, 21 (8%) as probable viral, and 18 (7%) had no documented evidence of infection. Three indications accounted for 73% of antimicrobial prescriptions: skin/soft tissue infection; ear, nose and throat infection; and urinary tract infection. Overall guideline compliance was 64%. Conclusions: Several areas for AMS interventions to optimize antimicrobial prescribing in the ED were identified, including targeted local and national guideline reviews, delayed prescribing, improved point-of-care testing and prescriber and patient education.

International trade and investment law: a new framework for public health and the common good.

BACKGROUND: International trade and investment agreements can have positive outcomes, but also have negative consequences that affect global health and influence fundamental health determinants: poverty, inequality and the environment. This article proposes principles and strategies for designing future international law to attain health and common good objectives. ARGUMENT: Basic principles are needed for international trade and investment agreements that are consistent with the common good, public health, and human rights. These principles should reflect the importance of reducing inequalities, along with social and environmental sustainability. Economic growth should be recognised as a means to common good objectives, rather than an end in itself. Our favoured approach is both radical and comprehensive: we describe what this approach would include and outline the strategies for its implementation, the processes and capacity building necessary for its achievement, and related governance and corporate issues. The comprehensive approach includes significant changes to current models for trade and investment agreements, in particular (i) health, social and environmental objectives would be recognised as legitimate in their own right and implemented accordingly; (ii) changes to dispute-resolution processes, both state-to-state and investor-state; (iii) greater deference to international legal frameworks for health, environmental protection, and human rights; (iv) greater coherence across the international law framework; (v) limitations on investor privileges, and (vi) enforceable corporate responsibilities for contributing to health, environmental, human rights and other common good objectives. We also identify some limited changes that could be considered as an alternative to the proposed comprehensive approach. Future research is needed to develop a range of model treaties, and on the means by which such treaties and reforms might be achieved. Such research would focus also on complementary institutional reforms relevant to the United Nations and other international agencies. Advocacy by a range of communities is needed for effective change. Reform will require informed debate, determined engagement with decision-makers and stakeholders, and some agreement across health, social and environmental sectors on alternatives. CONCLUSIONS: Current frameworks of international law that govern trade and economic development need radical change, in relation to treaty processes, content, and contexts, to better attain public health objectives.

Key design features of a new smokefree law to help achieve the Smokefree Aotearoa.

AIM: To design new tobacco control legislation to achieve the New Zealand Government's 2025 smokefree goal. METHOD: An original analysis of the legislative options for New Zealand tobacco control. RESULTS: 'Business as usual' is most unlikely to achieve smoking prevalence that is less than 5% by 2025. Key components of a new Act would ideally include plans and targets with teeth, a focus on the industry, a focus on the product, reduction of supply, and a whole-of-society approach to promote consistency in policy implementation through: i) a public duty on government agencies to act consistently with smokefree law; ii) a general duty on those associated with the tobacco/nicotine industry in relation to tobacco control objectives; and iii) a principle requiring international treaties to be interpreted consistently with tobacco control objectives. CONCLUSION: Strategies such as those identified in this Viewpoint should be explored further as part of urgently needed planning to achieve the New Zealand Government's goal for Smokefree Aotearoa by 2025.