Antimicrobial stewardship programme implementation in the UAE: perspectives of key stakeholders using Consolidated Framework for Implementation Research.

BACKGROUND: Many studies report antimicrobial stewardship programme (ASP) implementation, but these are limited by a lack of theoretical underpinning. This may lead to missing key factors that are likely to influence the successful or unsuccessful implementation. AIM: To explore key stakeholders' perspectives of ASP implementation in UAE hospitals, with a focus on facilitators and barriers. METHODS: The study employed a qualitative approach using semi-structured interviews conducted with ASP stakeholders involved in clinical use of antimicrobials at the individual patient level and including ASP team members and non-members. An interview schedule based on published literature and grounded in the Consolidated Framework for Implementation Research (CFIR) was developed, reviewed, and piloted. Recruitment was via purposive and snowball sampling. Interviews were recorded, transcribed, and thematically analysed by two independent researchers using CFIR as a coding framework. FINDINGS: Data saturation was achieved at 31 interviews. Multiple CFIR constructs were identified as implementation facilitators or barriers. Facilitators included external policy requirements (both national and international), leadership support, stakeholders' engagement, collaborative culture, effective communication, and forward planning. Barriers included blame culture, complexity of ASP implementation, and a shortage of expert personnel. CONCLUSION: Numerous facilitators and barriers to ASP implementation from a stakeholders' perspective were identified in this research. The value of early leadership engagement to support provision of required resources, a need for effective planning and establishment of multiple engagement techniques, and valuable communication with healthcare providers are the main recommendations emerging to support improvement in clinical practice.

The impact of COVID-19 on antimicrobial stewardship programme implementation in hospitals - an exploration informed by the Consolidated Framework for Implementation Research.

INTRODUCTION AND OBJECTIVES: The disruption of antimicrobial stewardship programmes (ASPs) caused by coronavirus disease 2019 (COVID-19) has been recognized but not explored in depth. This study used a theoretical, qualitative approach to understand the impact of COVID-19 on ASP implementation in hospitals. METHODS: Semi-structured online interviews, informed by the Consolidated Framework for Implementation Research (CFIR), were conducted with ASP team members and non-members in hospitals. Participants were recruited via purposeful and snowball sampling with interviews video recorded, transcribed and analysed independently by two researchers based on mapping against CFIR constructs. RESULTS: Thirty-one interviews were conducted across 11 hospitals. The following themes were identified: (i) increased complexity of ASP implementation and changes in prescribing behaviour influenced by COVID-19; (ii) adaptations, networking and cosmopolitanism to enhance integration of COVID-19 management into ASP services; and (iii) adaptations and networking to support continuity of the ASP implementation process. A disruption to pre-pandemic ASP activities was reported, with complexity of COVID-19 overwhelming the healthcare system. ASP team members and services showed an ability to adapt and repurpose roles to respond to the pandemic. Interventions included developing national guidelines for treatment of patients with COVID-19 and contributing to guideline management and monitoring. A gradual restoration of ASP activities was perceived. Technological adaptations and enhancements in networking were reported as positive impacts of the pandemic. CONCLUSION: Despite the initial disruption of ASP implementation caused by the pandemic, successful adaptation and evolution of ASP services reflects the high value and adaptability of ASP implementation in hospitals in the United Arab Emirates.

Phytochemical composition and antioxidant properties of methanolic extracts of whole and dehulled Bambara groundnut (Vigna subterranea) seeds.

The distribution of phytochemicals and their contribution to antioxidant potentials in whole and dehulled Bambara groundnut (BGN) seeds was evaluated. Whole BGN seeds were sorted using the testa and hilium colour and further grouped into whole and dehulled BGN seeds. Extractions of both whole and dehulled BGN seeds was done using methanol and the extracts assayed for total phenolics (TPC), flavanol, flavonol, anthocyanin content, oxygen radical absorbance capacity (ORAC) and ferric reducing antioxidant power (FRAP). Methanolic extract of whole BGN seed exhibited higher flavanol and flavonol content as well as significantly higher in-vitro antioxidant activities than dehulled BGN seeds. The TPC of whole BGN seed extract ranged from 3.6 to 11.0 GAE/g, while that of dehulled BGN ranged from 2.7 to 3.2 GAE/g. Identification of phenolics in whole and dehulled BGN seed extract using UPLC-qTOF-MS, revealed the presence of monoterpenoids (iridoids), phenolic acids, flavonoids and lignans. Bivariate correlations showed anthocyanin demonstrated weak positive correlation between flavanol, flavonol and ORAC for whole BGN seed extract; and negative correlation between flavanol, TPC, FRAP and ORAC for dehulled BGN. Aside the effect of dehulling, whole BGN seeds exhibited the presence of phytochemicals with beneficial properties for food and industrial application.

Use of Normalization Process Theory to explore key stakeholders' perceptions of the facilitators and barriers to implementing electronic systems for medicines management in hospital settings.

BACKGROUND: Limited data exist on the facilitators and barriers to implementing electronic systems for medicines management in hospitals. Whilst numerous studies advocate system use in improved patient safety and efficiency within the health service, their rate of adoption in practice has been slow. OBJECTIVE: To explore the perceptions of key stakeholders towards the facilitators and barriers to implementing electronic prescribing systems, robotic pharmacy systems, and automated medication storage and retrieval systems in public hospital settings using Normalization Process Theory as a theoretical framework. METHODS: Individual face-to-face semi-structured interviews were conducted in three public hospitals in Ireland with 23 consenting participants: nine nurses; four pharmacists; two pharmacy technicians; six doctors; and two Information Technology managers. RESULTS: Enhanced patient safety and efficiency in healthcare delivery emerged as key facilitators to system implementation, as well as the need to have clinical champions and a multi-disciplinary implementation team to promote engagement and cognitive participation. Key barriers included inadequate training and organisational support, and the need for ease and confidence in system use to achieve collective action. CONCLUSIONS: Many themes that are potentially transferable to other national settings have been identified and extend the evidence base. This will assist organisations around the world to better plan for implementation of medication-related eHealth systems.

Mapping hospital antimicrobial stewardship programmes in the Gulf Cooperation Council states against international standards: a systematic review.

BACKGROUND: While there is evidence of implementation of antimicrobial stewardship programmes (ASPs) in the Gulf Cooperation Council (GCC) states, there has been limited benchmarking and mapping to international standards and frameworks. AIM: To critically appraise and synthesize the evidence of ASP implementation in GCC hospitals with reference to the framework of the Centers for Disease Control and Prevention (CDC), identifying key facilitators and barriers. METHODS: A systematic review protocol was developed based on Preferred Reporting Items for Systematic Reviews and Meta-analyses for Protocols guidelines. Five electronic databases were searched for studies published in English from 2010 onwards. Study selection, quality assessment and data extraction were performed independently by two reviewers. A narrative synthesis was conducted with ASP interventions mapped to CDC core elements. FINDINGS: Seventeen studies were identified, most of which (N=11) were from Saudi Arabia. Mapping to the CDC framework identified key areas of strengths and weaknesses in reporting implementation. Studies more commonly reported core elements of pharmacy expertise, selected aspects of implementation actions, tracking, antibiotic use and resistance, and education. Little emphasis was placed on the reporting of leadership and accountability. Key implementation facilitators were physician and organization support, information systems and education, and barriers were dedicated staff, workload and funding. CONCLUSION: There is a need to enhance the reporting of ASP implementation in GCC hospitals. The CDC framework should be used as a guide during the development, implementation and reporting of ASP interventions. Action is required to identify facilitators and overcome barriers, where possible.

Effect of Wheat Bran Incorporation on the Physical and Sensory Properties of a South African Cereal Fried Dough.

This study investigated the effect of wheat bran (WB) supplementation on the physical and sensory properties of a South African cereal fried dough (magwinya). The physical properties, instrumental texture, and sensory profile were determined for magwinya (100:0, control) and for wheat flour to wheat-bran ratios of 95:5 (MWB5), 90:10 (MWB10), 85:15 (MWB15), and 80:20 (MWB20). An increase in the proportion of WB in the fried dough showed no significant difference on the specific volume (1.47-1.54) of samples. The chroma value (30.19-22.29), lightness (35.92-28.98), and hue angle (55.03-47.77) decreased, while ∆E increased distinctly with the addition of WB. Magwinya supplemented with WB was less cohesive and easy to chew. Significant correlations were found between instrumental hardness and sensory springiness (r = -0.63; p < 0.05), as well as between instrumental cohesiveness and chewiness (r = -0.71; p < 0.01). Two principal components were identified, which accounted for 85.1% of the variance in the instrumental data. A substitution level of 5 and 10% WB was similar to the sensory properties of the control in taste, texture, and overall acceptability and can replace part of the wheat flour in the cereal fried dough production.

Polyphenolic and Physicochemical Properties of Simple-Spined Num-Num (Carissa edulis) Fruit Harvested at Ripe Stage of Maturation.

Wildly grown in most regions of the world, Carissa edulis is a highly underutilised fruit with significant antioxidant characteristics. The phyto and physicochemical properties of C. edulis berries at different stages of ripening are evaluated in this work. Total flavonoids (TF), total phenolic content (TPC) and antioxidant activity were determined spectrophotometrically, while concentration of polyphenols was determined using liquid chromatography coupled to diode array detection and electrospray ionization mass spectrometry. Results showed that antioxidant activity was lowest (18.36 ± 0.12 mg TE/g) in RS3 and decreased with TPC upon increased ripening. Conversely, TF increased with ripening progression with TF found to be highest in RS3 (5.92 ± 0.03 mg CE/g). Identified phenolic acids in C. edulis were quinic acid, protocatechuoyl-hexose, neochlorogenic acid, chlorogenic acid, cryptochlorogenic acid and dicaffeoylquinic acid. Identified flavonoids included rutin, catechin, procyanidin dimer, procyanidin trimer, quercetin-3-O-glucosyl-xyloside, quercetin-3-O-robinobioside, quercetin-3-O-glucoside and quercetin-3-OH-3-methylglutaryl-glucoside. Physicochemical properties of C. edulis varied among samples with sugar/acid ratio of C. edulis ranging from 25.70 for RS1 to 50.36 for RS3. Ripening stage of C. edulis undoubtedly affects the phyto and physicochemical properties of C. edulis.

Development of consensus-based national antimicrobial stewardship competencies for UK undergraduate healthcare professional education.

BACKGROUND: Healthcare professionals are involved in an array of patient- and medicine-related stewardship activities, for which an understanding and engagement with antimicrobial stewardship (AMS) is important. Undergraduate education provides an ideal opportunity to prepare healthcare professionals for these roles and activities. AIM: To provide UK national consensus on a common set of antimicrobial stewardship competencies appropriate for undergraduate healthcare professional education. METHODS: A modified Delphi approach comprising two online surveys delivered to a UK national panel of 21 individuals reflecting expertise in prescribing and medicines management with regards to the education and practice of nurses and midwives, pharmacists, physiotherapists, and podiatrists; and antimicrobial prescribing and stewardship. Data collection took place between October and December 2017. FINDINGS: A total of 21 participants agreed to become members of the expert panel, of whom 19 (90%) completed round 1 questionnaire, and 17 (89%) completed round 2. Panelists reached a consensus, with consistently high levels of agreement reached, on six overarching competency statements (subdivided into six domains), and 55 individual descriptors essential for antimicrobial stewardship by healthcare professionals. CONCLUSION: Due to the consistently high levels of agreement reached on competency statements and their associated descriptors, this competency framework should be used to direct education for undergraduate healthcare professionals, and those working in new clinical roles to support healthcare delivery where an understanding of, and engagement with, AMS is important. Although the competencies target basic education, they can also be used for continuing education.

Phenolics and essential mineral profile of organic acid pretreated unripe banana flour.

Banana fruit (Musa spp) though rich in essential minerals, has also been implicated for the presence of phytochemicals which nonetheless beneficial, can also act as mineral inhibitors when in forms such as phenolic compounds, phytates and tannins. This study assayed the essential macro and trace minerals as well as phenolic compounds present in unripe banana flour (UBF) obtained from the pulp of four different cultivars. Unripe banana flour was processed by oven drying in a forced air oven dryer at 70°C upon pretreatment with ascorbic, citric and lactic acid. Organic acid pretreatment was done separately on each unripe banana cultivar at concentrations of 10, 15 and 20g/L. Phenolic compounds were profiled using liquid chromatography mass spectrometry electrospray ion (LC-MS-ESI) while essential minerals were determined using inductively coupled plasma atomic emission spectroscopy (ICP-AES) and mass spectroscopy (ICP-MS) respectively. Results of LC-MS-ESI assay of phenolics revealed the presence of flavonoids: epicatechin and myricetin 3-O-rhamnosyl-glucoside in varying concentrations in UBF. Essential mineral profile indicated that Zinc had the least occurrence of 3.55mg/kg (p<0.05), while potassium was the most abundant mineral at 14746.73mg/kg in UBF of all four banana cultivars. Correlation between phenolic compounds and essential minerals using Pearson's Correlation Coefficient test revealed weak and inverse association between flavonoids and most macro and trace minerals present in UBF samples. Organic acid pretreatment thus exhibited little effect on phenolics and essential minerals of UBF samples, though, inhibitory influence of phenolic compounds was recorded on essential minerals.

A qualitative study of determinants of patient behaviour leading to an infection related hospital admission.

Objectives To describe and understand the determinants of patients' behaviours surrounding admission to hospital for an acute infective episode Method Patients admitted to the infection or acute medicine admission units of a major Scottish teaching hospital and commenced on antibiotic therapy after admission were included. Semi-structured face-to-face interviews were conducted using a pre-piloted interview schedule guide that focused on gathering information about patient behaviours and experiences prior to admission to hospital with an acute infection. Interviews were audio-recorded, transcribed verbatim and analysed using the Framework Approach. Emerging themes were matched to the Theoretical Domains Framework of behavioural determinants. Results Twenty-one patients consented to participate and 18 transcripts were suitable for analysis. The most common infections were those of the skin, soft tissue and respiratory tract. From the patients' perspectives, behavioural determinants that appeared to impact their admission to hospital were principally their knowledge, beliefs of consequences, the environmental context and resources (mainly out-of-hours services), social influences and their own emotions. Determinants such as knowledge of the signs and symptoms, beliefs of consequences and environmental context were facilitators of health seeking behaviours. The main barriers were a lack of awareness of consequences of infection potentially leading to delayed admission impacting infection severity, stay in secondary care and resource utilisation. Conclusions This study has shown that any initial patient-centred intervention that is proposed to change patient behaviour needs to be based on behavioural determinants emerging in this research. The intervention may include aspects such as patient education on resources available out-of-hours and ways to access the healthcare system, education on recognising signs of infection leading to prompter treatment and positive reinforcement for patients who present with recurrences of infection.

Morphological, physicochemical, and antioxidant profile of noncommercial banana cultivars.

Banana cultivars--Luvhele (MusaABB), Mabonde (MusaAAA), and Muomva-red (Musa balbisiana) --were characterized for morphological, physicochemical, and antioxidant properties. All three cultivars varied significantly (P < 0.05) in their morphology, pH, titratable acidity and total soluble solids with no significant difference in their ash content. Individual cultivars showed variations in flour starch granule when observed using a scanning electron microscope. Characterization of cultivars for total polyphenols (TPs) and antioxidant activity upon pretreatment with ascorbic, citric, and lactic acid shows that the 1,1-diphenyl-2-picrylhydrazyl (DPPH) radical scavenging assay of samples varied significantly as Muomva-red cultivar (1.02 ± 0.01 mg GA/g) expressed the highest DPPH activity at lactic acid concentration of 20 g/L. Total polyphenol content was also highest for Muomva-red [1091.76 ± 122.81 mg GAE/100 g (d.w.)]. The high amount of TPs present in these cultivars make them suitable source of bio-nutrients with great medicinal and health functions.

Effect of organic acid pretreatment on some physical, functional and antioxidant properties of flour obtained from three unripe banana cultivars.

Unripe banana flour (UBF) obtained from organic acid pretreatment of pulp from three non-commercial cultivars were profiled for physical, functional and antioxidant properties. UBF showed marked significant differences (p<0.05) in colour (CIEL(∗)a(∗)b(∗) and CIELCH) and water holding capacity with no significant difference in oil holding capacity. The total polyphenol content (TPC) and 1,1-diphenyl-2-picrylhydrazyl (DPPH) differed significantly with M-red UBF recording high TPC (1130.39 ± 27.26 mg GAE/100g d.w.) at 10 g/L citric acid pretreatment. Correlation analysis between TPC and DPPH showed very strong positive correlation for Mabonde UBF in citric and lactic acid pretreatment (r = 0.999, p < 0.01; r = 0.985, p < 0.01), while inverse correlation was recorded in M-red UBF for ascorbic and lactic acid pretreatment (r = -0.031; r = -0.137). Organic acid pretreatment enhances the physical and antioxidant properties of UBF hitherto absent in composite food formulations.

A cross-sectional survey of antimicrobial stewardship strategies in UK hospitals.

WHAT IS KNOWN AND OBJECTIVE: Antimicrobial stewardship programmes describe strategies to optimize antimicrobial prescribing and utilization, minimize resistance and improve patient outcomes. Strategies in hospitals are usually implemented by multidisciplinary antimicrobial teams (AMTs). The objective of this study was to describe the profile and activities of AMTs within hospitals in the United Kingdom (UK). METHOD: All hospitals within the UK (n = 836) were included, and a prepiloted questionnaire was mailed to the 'Director of Pharmacy'. Non-respondents were mailed up to two reminder questionnaires at two-weekly intervals. Main outcome measures are as follows: existence and remit of the AMTs; availability of antimicrobial-prescribing policies, aims, scope and methods of dissemination; and monitoring and feedback provided on antimicrobial policy adherence. RESULTS: Response rate was 33% (n = 273). Completed questionnaires analysed were n = 226. Eighty-two (n = 186) of respondents indicated the presence of an AMT within the hospital, with 95% of these (n = 177) reporting an antimicrobial pharmacist as part of the team. All AMTs (n = 186) were involved in development of an antimicrobial policy and almost all (99% n = 184) promoted adherence and restricting use of specific antimicrobials (97% n = 180). Ninety-eight per cent of respondents (n = 222) reported the availability of a local antimicrobial-prescribing policy within the hospital with this disseminated mainly through the hospital intranet (98% n = 217). Adherence to policy was measured mainly through audits measuring the appropriateness of antimicrobial use against the local policy (76% n = 169). Hospitals in England (P = 0·010), tertiary care hospitals (P = 0·021) and bed capacity >500 (P < 0·001) were more likely to have an AMT, as were hospitals with an accident and emergency department (P < 0·001), an infectious diseases unit (P = 0·019) and a microbiology department (P < 0·001). Audits to measure policy adherence were more likely (P < 0·001) if an AMT was present. The only variable retained in bivariate logistic regression was the presence of a microbiology unit, with an odds ratio of 14·1 (95% CI 6·02-33·33, P < 0·001). WHAT IS NEW AND CONCLUSIONS: Although most respondents reported an antimicrobial-prescribing policy, less had an AMT. Despite recent government and regional initiatives, further improvements in antimicrobial stewardship are still required.

Functional Properties and Postharvest Utilization of Commercial and Noncommercial Banana Cultivars.

Banana (Musa spp.) is one of the world's most important crops cultivated in tropical and subtropical regions of the world. Banana is a major source of macro-elements, especially potassium, and contains health-beneficial ingredients such as resistant starch, total dietary fibers, rapidly digestible starch, and slowly digestible starch. Oligosaccharides (fructooligosaccharides and inulin) and polyphenols ((+)-catechin, (-)-epicatechin, (-)-epigallocatechin, and gallic acid) are other ingredients present in bananas that have found application in the prevention of muscular contractions, regulation of blood pressure, prevention of colon cancer and diabetes, and in the cure of intestinal disorders when unripe. This review identifies the different commercial and noncommercial banana cultivars and their utilization. Commercial cultivars include Williams (M. acuminata cv. Williams), Dwarf Cavendish (M. acuminata cv. Petite Nain), Chinese Cavendish (M. acuminata cv. Chinese Cavendish), Grand Nain (M. acuminata cv. Grand Nain), and Goldfinger (M. acuminata cv. Goldfinger), with Mabounde and Luvhele identified as noncommercial varieties. Banana postharvest utilization includes its use as functional foods, prebiotics, probiotics, nutraceuticals, and processing into value-added products.

Pharmacist prescribing in the UK - a literature review of current practice and research.

OBJECTIVE: To review the research literature to date on pharmacist prescribing in the United Kingdom (UK) and to explore the main areas of care and practice settings including any benefits and limitations. FINDINGS: There are two models of pharmacist prescribing in the UK: pharma\cist supplementary prescribing (SP) introduced in 2003, involving a voluntary partnership between the responsible independent prescriber (a physician or a dentist), the supplementary prescriber and the patient, to implement an agreed patient-specific clinical management plan; and pharmacist independent prescribing (IP) introduced in 2006, responsible for the assessment and consequent management, including prescribing of both undiagnosed and diagnosed conditions. There have been narrative reports of pharmacist SP in different health care settings including primary care, community pharmacies, secondary care and at the primary/secondary care interface; published research within these areas of care is conflicting as to which setting is more suitable for pharmacist prescribing. Initial research reports that almost 50% of pharmacist supplementary prescribers self-reported prescribing with both benefits of and barriers to implementing SP. Research involving other healthcare professionals has indicated that encroachment of traditional roles is likely to occur because of the advent of pharmacist prescribing. A small-scale study has concluded that patients are likely to accept pharmacist prescribing favourably, with another study showing pharmacist prescribing leading to improved adherence to guidelines. There is no published research yet available about practices involving pharmacist IP. DISCUSSION: Most of the literature focuses on pharmacists' perceptions of SP, with little information referring to other stakeholders, including patients. There is also limited published research focusing on clinical and economic outcomes of pharmacist SP. CONCLUSION: This is a rapidly changing aspect of pharmacy practice in the UK, particularly with the more recent introduction of pharmacist IP. It is likely that this area of research will expand rapidly over the coming years.