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.

Potential health risks of complementary alternative medicines in HIV patients.

OBJECTIVES: To determine the prevalence and purpose of complementary alternative medicines (CAMs) use in people receiving treatment for HIV infection. To identify and quantify potential health risks of CAM use in this population and to explore options for improved pharmacovigilance. METHODS: Cross-sectional questionnaire survey of 293 patients receiving antiretroviral (ARV) therapy at three specialist HIV out-patient clinics in central London, UK. The use of herbal medicines and supplements was explored, and potentially adverse side effects or significant drug interactions with conventional therapies were identified. RESULTS: Of the 293 patients included, 61% (n=179) were taking herbal remedies or supplements and 35% (n=103) were using physical treatments. Twenty-seven per cent (n=80) used a combination of both. Twenty per cent (n=59) potentially compromised their HIV management through using CAM therapy. Ten per cent (n=29) were advised to stop their CAMs and 15% (n=43) were made aware of potential drug interactions and adverse effects and were advised to monitor their care. CONCLUSIONS: There are potentially significant health risks posed by the concomitant use of CAMs in patients taking ARV therapy. Medical practitioners need to be able to identify CAM use in HIV-positive patients and recognize potential health risks. Patients should be encouraged to disclose CAM use to their clinicians and other healthcare professionals.

The influence of hydrocolloid patch composition on the bioavailability of triamcinolone acetonide in humans.

Triamcinolone acetonide (TACA) is a corticosteroid; it is used in the systemic and topical treatment of a variety of inflammatory conditions, including eczema and psoriasis. Conventionally, for topical use, the drug is formulated in a cream or ointment. However, it has been observed in vitro that percutaneous penetration of corticosteroids can be influenced by hydrocolloid patches. Corticosteroids produce a pallor or blanching when applied to the skin that correlates with anti-inflammatory activity; this property has been used extensively as a bioassay. The aim of this study therefore was to evaluate the occlusive properties of a range of hydrocolloid patches containing TACA on the drug's penetration in vivo using visual assessment and a graded multiple measurement. The in vivo hydration of these dermatological patches was also investigated. Statistical analysis of the weight gains of patches containing either NaCMC 39% or pectin 39% showed that there was a significant difference in the rates of hydration of the two types of patch (p < .005). An increase in application time of the hydrocolloid patches allowed more TACA to be released, which was illustrated by an increase in both the maximum percentage total possible score (%TPS) values and AUC, although changes in the hydrocolloid composition did not significantly alter the blanching response. All of the patches adhered well, were unobtrusive to the normal activity of the wearers, and showed great potential for the convenient, localized, prolonged delivery of drugs to the skin.

An in-vitro study of the effect of hydrocolloid patch occlusion on the penetration of triamcinolone acetonide through skin in man.

The aim of this study was to evaluate the effect of occlusion using hydrocolloid-containing patches on in-vitro triamcinolone acetonide (TACA) penetration of the epidermis while monitoring the uptake of water by the patches as a result of transepidermal water loss. The hydrocolloid patches were a laminate of a pressure-sensitive hydrophobic adhesive (containing a dispersion of 39% of either pectin or carmellose sodium) and a polyethylene film. The diffusion of a representative corticosteroid (TACA) through isolated epidermal sheet was shown to depend on the site from which the skin was removed. The two patch-types exhibited markedly different hydration rates when applied to the membranes. For example, after 96 h the carmellose sodium patch showed ten times the weight increase of the pectin patch. Epidermal diffusion rates were, however, similar, both showing a 3-4-fold enhancement over unoccluded conditions. The increase in TACA diffusion with the patches can be explained by the increase in skin hydration that occurs during occlusion. Despite the large differences in transepidermal water transfer through the epidermal membranes with the two types of hydrocolloid patch, however, this level of stratum corneum hydration was apparently similar. As the rate of diffusion was also independent of hydrocolloid patch component, it seems possible that the hydrophobic component of the patch matrix may also influence the level of skin hydration and consequent drug diffusion.