Effectiveness of behavioural interventions to reduce urinary tract infections and Escherichia coli bacteraemia for older adults across all care settings: a systematic review.

BACKGROUND: Escherichia coli bacteraemia rates in the UK have risen; rates are highest among older adults. Previous urinary tract infections (UTIs) and catheterization are risk factors. AIM: To examine effectiveness of behavioural interventions to reduce E. coli bacteraemia and/or symptomatic UTIs for older adults. METHODS: Sixteen databases, grey literature, and reference lists were searched. Titles and/or abstracts were scanned and selected papers were read fully to confirm suitability. Quality was assessed using Critical Appraisal Skills Programme guidelines and Scottish Intercollegiate Guidelines Network grading. FINDINGS: Twenty-one studies were reviewed, and all lacked methodological quality. Six multi-faceted hospital interventions including education, with audit and feedback or reminders reduced UTIs but only three supplied statements of significance. One study reported decreasing catheter-associated UTI (CAUTI) by 88% (F (1,20) = 7.25). Another study reported reductions in CAUTI from 11.17 to 10.53 during Phase I and by 0.39 during Phase II (χ2 = 254). A third study reported fewer UTIs per patient week (risk ratio = 0.39). Two hospital studies of online training and catheter insertion and care simulations decreased CAUTIs from 33 to 14 and from 10.40 to 0. Increasing nursing staff, community continence nurses, and catheter removal reminder stickers reduced infection. There were no studies examining prevention of E. coli bacteraemias. CONCLUSION: The heterogeneity of studies means that one effective intervention cannot be recommended. We suggest that feedback should be considered because it facilitated reductions in UTI when used alone or in multi-faceted interventions including education, audit or catheter removal protocols. Multi-faceted education is likely to be effective. Catheter removal protocols, increased staffing, and patient education require further evaluation.

Investigation of community carriage rates of Clostridium difficile and Hungatella hathewayi in healthy volunteers from four regions of England.

Faecal samples from 1365 healthy asymptomatic volunteers from four regions in England were screened for the presence of Clostridium difficile between December 2013 and July 2014. The carriage rate of C. difficile in healthy patients was 0.5%, which is lower than reported previously. This study demonstrates that the true community reservoir of C. difficile in the healthy UK population is very low and is, therefore, unlikely to be a reservoir for infections diagnosed in the hospital setting.

Exploring why a complex intervention piloted in general practices did not result in an increase in chlamydia screening and diagnosis: a qualitative evaluation using the fidelity of implementation model.

BACKGROUND: Chlamydia trachomatis (chlamydia) is the most commonly diagnosed sexually transmitted infection (STI) in England; approximately 70% of diagnoses are in sexually active young adults aged under 25. To facilitate opportunistic chlamydia screening in general practice, a complex intervention, based on a previously successful Chlamydia Intervention Randomised Trial (CIRT), was piloted in England. The modified intervention (3Cs and HIV) aimed to encourage general practice staff to routinely offer chlamydia testing to all 15-24 year olds regardless of the type of consultation. However, when the 3Cs (chlamydia screening, signposting to contraceptive services, free condoms) and HIV was offered to a large number of general practitioner (GP) surgeries across England, chlamydia screening was not significantly increased. This qualitative evaluation addresses the following aims: a) Explore why the modified intervention did not increase screening across all general practices. b) Suggest recommendations for future intervention implementation. METHODS: Phone interviews were carried out with 26 practice staff, at least 5 months after their initial educational workshop, exploring their opinions on the workshop and intervention implementation in the real world setting. Interview transcripts were thematically analysed and further examined using the fidelity of implementation model. RESULTS: Participants who attended had a positive attitude towards the workshops, but attendee numbers were low. Often, the intervention content, as detailed in the educational workshops, was not adhered to: practice staff were unaware of any on-going trainer support; computer prompts were only added to the female contraception template; patients were not encouraged to complete the test immediately; complete chlamydia kits were not always readily available to the clinicians; and videos and posters were not utilised. Staff reported that financial incentives, themselves, were not a motivator; competing priorities and time were identified as major barriers. CONCLUSION: Not adhering to the exact intervention model may explain the lack of significant increases in chlamydia screening. To increase fidelity of implementation outside of Randomised Controlled Trial (RCT) conditions, and consequently, improve likelihood of increased screening, future public health interventions in general practices need to have: more specific action planning within the educational workshop; computer prompts added to systems and used; all staff attending the workshop; and on-going practice staff support with feedback of progress on screening and diagnosis rates fed back to all staff.

Implementation of antimicrobial stewardship interventions recommended by national toolkits in primary and secondary healthcare sectors in England: TARGET and Start Smart Then Focus.

OBJECTIVES: To assess and compare the implementation of antimicrobial stewardship (AMS) interventions recommended within the national AMS toolkits, TARGET and Start Smart Then Focus, in English primary and secondary healthcare settings in 2014, to determine the prevalence of cross-sector engagement to drive AMS interventions and to propose next steps to improve implementation of AMS. METHODS: Electronic surveys were circulated to all 211 clinical commissioning groups (CCGs; primary sector) and to 146 (out of the 159) acute trusts (secondary sector) in England. Response rates were 39% and 63% for the primary and secondary sectors, respectively. RESULTS: The majority of CCGs and acute trusts reported reviewing national AMS toolkits formally or informally (60% and 87%, respectively). However, only 13% of CCGs and 46% of acute trusts had developed an action plan for the implementation of these toolkits. Only 5% of CCGs had antimicrobial pharmacists in post; however, the role of specialist antimicrobial pharmacists continued to remain embedded within acute trusts, with 83% of responding trusts having an antimicrobial pharmacist at a senior grade. CONCLUSIONS: The majority of healthcare organizations review national AMS toolkits; however, implementation of the toolkits, through the development of action plans to deliver AMS interventions, requires improvement. For the first time, we report the extent of cross-sector and multidisciplinary collaboration to deliver AMS interventions in both primary and secondary care sectors in England. Results highlight that further qualitative and quantitative work is required to explore mutual benefits and promote best practice. Antimicrobial pharmacists remain leaders for implementing AMS interventions across both primary and secondary healthcare sectors.

Supporting general practices to provide sexual and reproductive health services: protocol for the 3Cs & HIV programme.

OBJECTIVES: Sexually transmitted infections, HIV and unplanned pregnancies continue to be a major public health problem in England, especially in young adults. Strengthening the provision of free condoms, HIV testing, chlamydia screening and contraception within primary care will contribute to reducing poor sexual and reproductive health outcomes. Recent research demonstrated the benefit for general practices of educational support visits based on behaviour change theory. Public Health England (PHE) has piloted an educational training programme to improve the delivery of sexual health services and HIV testing within general practice. STUDY DESIGN & METHODS: The 3Cs & HIV programme used practice based workshops to improve staffs' awareness and skills in order to increase opportunistic offers of chlamydia testing, provision of contraceptive service information and free condoms (the '3Cs') to 15-24 year olds and HIV testing according to national guidelines. The programme was based on the theory of planned behaviour and has been implemented using a stepped wedge design. Process evaluation, testing and diagnosis data, plus qualitative interviews were all used in the evaluation. The primary outcome measures were chlamydia testing and diagnosis rates. Secondary outcome measures were HIV testing and diagnoses rates within each practice and rates of consultations where long acting reversible contraceptives had been discussed. CONCLUSION: A key strength of the 3Cs & HIV programme has been the evidence base underpinning the development of the resources and the formal process evaluation of its implementation. The programme was designed to encourage sustainable relationships between general practice staff and local sexual health services as well as the knowledge, awareness and behaviours cultivated during the programme.

A pilot study to investigate the role of thymidylate synthase as a marker of prognosis for neoadjuvant chemotherapy in gastric and gastro-oesophageal junction adenocarcinoma.

Aims and Background. Patients in the United Kingdom with operable gastric and gastro-oesophageal junction (GOJ) tumours receive neoadjuvant chemotherapy. Our aim was to study the expression of thymidylate synthase (TS) enzyme in pre-treatment diagnostic biopsy specimens and investigate its clinical usefulness. Methods. A single-centre study was carried out in 45 patients with gastric and GOJ adenocarcinoma treated with neo-adjuvant chemotherapy according to the MAGIC protocol. TS expression was determined using immunohistochemistry. >10% tumour nuclei expression of TS was used as cut-off for positivity. Results. Forty-one (91%) of the 45 tumours expressed TS. There was no association between TS expression and lymph node status (P = 0.80), histological response (P = 0.30), and recurrence (P = 0.55). On univariate analysis, only N-stage (P = 0.02) and vascular invasion (P = 0.04) were associated with a poor prognosis. Patients with negative tumour TS expression had better outcome than those with positive expression. The overall 5-year survival rate was 100% in the TS negative versus 56% in TS positive group, but the difference was not statistically significant (P = 0.17). Conclusion. TS expression should be studied in a larger series of gastro-oesophageal cancers as a potential prognostic marker of prognosis to neo-adjuvant chemotherapy.

Is Helicobacter pylori antibiotic resistance surveillance needed and how can it be delivered?

BACKGROUND: Most patients are prescribed Helicobacter pylori treatment without culture and antibiotic susceptibility testing, as current guidance recommends that patients with recurrent dyspepsia should be tested for H. pylori using a non-invasive breath or faecal antigen test. AIMS: To determine the prevalence of H. pylori antibiotic resistance in patients attending endoscopy in England and Wales, and the feasibility of an antibiotic resistance surveillance programme testing. METHODS: We tested the antibiotic susceptibility of H. pylori isolates from biopsy specimens from 2063 of 7791 (26%) patients attending for endoscopy in Gloucester and Bangor, and 339 biopsy specimens sent to the Helicobacter Reference Unit (HRU) in London. Culture and susceptibility testing was undertaken in line with National and European methods. RESULTS: Helicobacter pylori were cultured in 6.4% of 2063 patients attending Gloucester and Bangor hospitals. Resistance to amoxicillin, tetracycline and rifampicin/rifabutin was below 3% at all centres. Clarithromycin, metronidazole and quinolone resistance was significantly higher in HRU (68%, 88%, 17%) and Bangor isolates (18%, 43%, 13%) than Gloucester (3%, 22%, 1%). Each previous course of these antibiotics is associated with an increase in the risk of antibiotic resistance to that agent [clarithromycin: RR = 1.5 (P = 0.12); metronidazole RR = 1.6 (P = 0.002); quinolone RR = 1.8 (P = 0.01)]. CONCLUSIONS: Helicobacter pylori infection is now uncommon in dyspeptic patients at endoscopy. A surveillance system is feasible and necessary to inform dyspepsia management guidance. Clinicians should take a thorough antibiotic history before prescribing metronidazole, clarithromycin or levofloxacin for H. pylori.

Developing best practice for fungal specimen submission--fungal audit of general practice.

The objective of this study was to investigate the management of suspected fungal nail infections by general practitioners (GPs) and determine whether guidance is sought when submitting specimens for investigation or treating cases. Questionnaires were sent to all GPs (n = 2420) served by five Health Protection Agency (HPA) collaborating laboratories in the South West of England. A total of 769 GPs responded - topical and oral antifungals were never used by 29% and 16% of GPs respectively. When antifungals were prescribed, topicals were normally given because of the severity of infection (32%); Amorolofine (53%) was the preferred choice. Oral antifungals were most often prescribed after receipt of a laboratory report (77%); Terbinafine was the preferred choice (86%). Seventy percent of GPs would only treat a suspected nail infection with oral antifungals after sending a sample for investigation, yet 27% never waited for a microscopy report before prescribing oral antifungal treatment. GPs routinely send specimens from suspected fungal nail infections for microbiological investigation, yet treatment is often prescribed before a result is received. With clinical signs of fungal infections often non-specific, GPs should rely on laboratory results before prescribing expensive and lengthy antifungal treatments. Laboratories could further reduce antifungal use by including guidance on microscopy and culture reports.

Consensus of microbiology reporting of ear swab results to primary care clinicians in patients with otitis externa.

Otitis externa is a ubiquitous inflammatory disease; although it arises most commonly from an infection, there is no consensus in the UK for the reporting of ear swab culture results. This study aims to review current microbiology laboratory reporting of ear swab specimens to primary care and reach an evidence-based consensus for a reporting policy. Fifty consecutive ear swab reports were reviewed from each of 12 laboratories in the South West region to determine and discuss reporting practice. The Health Protection Agency (HPA) GP Microbiology Laboratory Use Group reviewed the underlying evidence and worked towards a consensus of expert microbiology opinion for laboratory reporting of ear swab results using a modified version of the Delphi technique. A total of 487 reports from primary care were reviewed (54% female; 46% male). Cultures most commonly yielded Pseudomonas species (36%), Staphylococcus species (21%), Streptococcus species (15%) and fungi (11%). Five reporting policies were agreed: Policy 1: Common pathogens such as group A beta-haemolytic streptococci, Streptococcus pneumoniae, Staphylococcus aureus - Always reported by name with antibiotic susceptibilities. Policy 2: Pseudomonas species - Always reported, but antibiotic susceptibilities only reported in severe disease. Policy 3: Aspergillus, Candida, coliforms and Proteus species, as well as non-group A streptococci and anaerobes - Only reported if moderate numbers of colonies and it is the predominant organism present; if appropriate report antibiotic susceptibilities. Policy 4: Coagulase-negative staphylococci, diphtheroids and enterococci - Not reported by name; generic terms used and antibiotic susceptibilities not reported. Policy 5: When antibiotic susceptibilities reported these must include susceptibility to a topical antibiotic. It is suggested that laboratories should consider adopting this evidence-based reporting consensus for ear swab culture results from primary care patients with otitis externa.

Developing best practice for fungal specimen management: audit of UK microbiology laboratories.

This study represents an audit of microbiology laboratories in the UK to ascertain whether they are aware of, or follow, the Health Protection Agency (HPA) National Standard Methods Standard Operating Procedure (NSM SOP) for the investigation of dermatological specimens for superficial mycoses, or use a locally adapted version. A questionnaire audit was distributed to 179 NHS microbiology laboratories throughout England, Wales, Scotland and Northern Ireland. The NSM SOP was followed by 92% of laboratories for the microscopy of dermatological samples; light microscopy/ KOH digestion was used by 63% and fluorescence microscopy/KOH digestion by 29% of laboratories. Preliminary reports post-microscopy were issued by 98% of laboratories, with 93% issuing reports within 48 hours. Adherence to the NSM SOP guidelines for culture was low; only 34% of laboratories incubated microscopy-negative specimens for the recommended 14 days, while approximately 60% incubated microscopy-positive specimens for 21 days. The culture medium recommended by the NSM SOP was used in 82% of laboratories. Comments were added to culture reports by 51% of laboratories; most were added manually and comments varied between laboratories. Nail samples were the most common sample received from primary care, followed by skin and hair. These results show no significant difference in the rate of microscopy positives versus culture positives. Microscopy and culture are the easiest and cheapest methods available to UK laboratories for the investigation of suspected superficial fungal infections. Although most laboratories included in this audit claimed to follow the NSM SOP for microscopy and culture, these results show that the techniques used vary throughout the UK. To maximise the service provided to primary care, UK laboratories should use standardise methods based on the NSM SOP.

Best practice in primary care pathology: review 12.

This twelfth best practice review examines four series of common primary care questions in laboratory medicine: (i) antiepileptic drug monitoring; (ii) infectious diarrhoea; (iii) methicillin resistant Staphylococcus aureus; and (iv) brain natriuretic peptide. The review is presented in question-answer format, referenced for each question series. The recommendations represent a précis of guidance found using a standardised literature search of national and international guidance notes, consensus statements, health policy documents and evidence-based medicine reviews, supplemented by MEDLINE EMBASE searches to identify relevant primary research documents. They are not standards but form a guide to be set in the clinical context. Most are consensus rather than evidence-based. They will be updated periodically to take account of new information.

Staphylococcus aureus carriage in care homes: identification of risk factors, including the role of dementia.

The aim of this study was to investigate the prevalence and associated risk factors of methicillin-susceptible and methicillin-resistant Staphylocccus aureus (MSSA and MRSA) carriage in care homes, with particular focus on dementia. A point-prevalence survey of 748 residents in 51 care homes in Gloucestershire and Greater Bristol was undertaken. Dementia was assessed by the clock test or abbreviated mini-mental test. Nasal swabs were cultured for S. aureus on selective agar media. Multivariable analysis indicated that dementia was not a significant risk factor for MSSA (16.2%) or MRSA (7.8%); and that residents able to move around the home unassisted were at a lower risk of MRSA (P=0.04). MSSA carriage increased with increasing age (P=0.03) but MRSA carriage decreased with increasing age (P=0.05). Hospitalization in the last 6 months increased the risk of MSSA (P=0.04) and MRSA (P=0.10). We concluded that cross-infection through staff caring for more dependent residents may spread MRSA within care homes and from the recently hospitalized. Control of MSSA and MRSA in care homes requires focused infection control interventions.

Microbial investigation of venous leg ulcers.

OBJECTIVE: To investigate microbiology laboratory reporting policies, whether practitioners working in primary care adhered to the relevant guidelines when submitting swabs from venous leg ulcers (VLUs), and the impact of laboratory reports on antibiotic usage forVLUs. METHOD: Questionnaires were sent to all microbiology laboratories in England and Wales, and to clinicians who had submitted VLU swabs to one laboratory. RESULTS: Ninety-five (47%) laboratories responded. Laboratories processed a mean of 7.3 leg ulcer swabs/100,000 population/week but were often unable to identify the leg ulcer aetiology from the clinical details provided. All laboratories stated that they routinely reported group A haemolytic streptococci and meticillin-sensitive and resistant Staphylococcus aureus; 75% always reported antibiotic susceptibility for these isolates. The majority reported other beta-haemolytic streptococci. A total of 126 clinicians (64%) returned their questionnaires; 100 had confirmed in their swab submission that the ulcer was of venous aetiology and so were included in the analysis. Eighty per cent of the swabs were submitted in accordance with guidelines, with increased pain (61%) being the most common reason. Discharge/exudate (52%) and malodour (41%) were common reasons for swab submissions, even though the guidelines do not cite them as clinical signs of infection. Reporting of antibiotic susceptibilities was associated with increased antibiotic usage. CONCLUSION: Clinicians in primary care generally adhere to guidelines when submittingVLU specimens for microbiological investigation. Clinicians need to include clinical information with the swab so that laboratories can interpret the microbiology results. To reduce the use of antibiotics in the management ofVLUs, laboratories need to be selective in their organism and antibiotic-susceptibility reporting.

Strategies used to increase chlamydia screening in general practice: a qualitative study.

OBJECTIVES: To explore strategies used by chlamydia screening co-ordinators and practice staff to implement genital chlamydia screening within general practices. METHODS: Qualitative phenomenological study using individual semi-structured telephone interviews. Screening co-ordinators were selected purposively in Phase 1 and 2 areas of the Department of Health National Chlamydia Screening Programme in England, where there was significant screening in general practice. Open questions were asked about: the factors that determined high chlamydia screening rates; maintaining motivation for screening; and strategies to increase screening in general practices. RESULTS: Co-ordinators reported that successful screening practices had a champion who drove the screening process forward. These practices had normalized screening, so all at-risk patients were offered opportunistic screening whenever they attended. This was facilitated by a variety of time-saving methods including computer prompts, test kits in the reception area, youth clinics and receptionist involvement. Chlamydia screening was sustained through frequent reminders, newsletters containing chlamydia screening rates, and advertising to the 'at-risk' population from the screening team. Co-ordinators' enthusiasm and project management skills were as important as sexual health experience. Co-ordinators reported that to facilitate chlamydia screening across all practices, screening could be included in the General Medical Services (GMS) contract, and a higher national profile was needed amongst health professionals and the public. CONCLUSIONS: All practice staff need to be encouraged to become champions of the chlamydia screening programme through education, especially aimed at older clinicians and receptionists. The National Health Service should consider including chlamydia screening in the GMS contract. Increased public awareness will allow screening to be undertaken more quickly and by non-medical staff.

Best practice in primary care pathology: review 9.

This ninth best-practice review examines two series of common primary care questions in laboratory medicine: (i) potassium abnormalities and (ii) venous leg ulcer microbiology. The review is presented in question-and-answer format, referenced for each question series. The recommendations represent a précis of guidance found using a standardised literature search of national and international guidance notes, consensus statements, health policy documents and evidence-based medicine reviews, supplemented by MEDLINE EMBASE searches to identify relevant primary research documents. They are not standards but form a guide to be set in the clinical context. Most are consensus rather than evidence-based. They will be updated periodically to take account of new information.