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Introduction Health inequalities and antimicrobial resistance (AMR) present public health challenges. National guidance highlights the role of pharmacy professionals in reaching patients at risk of health inequalities.1 Pharmacy teams have the opportunity to involve their patients in shared decision-making and promote antimicrobial stewardship.2 An evidence gap exists regarding the association between factors that commonly contribute to health inequalities and antibiotic use amongst populations and risk of developing antibiotic-resistant infections. Aim To investigate the association between health inequalities, antibiotic use and risk of antibiotic-resistant infections in high-income countries, allowing pharmacy professionals to better understand the challenges and their role in tackling health inequalities and AMR. Methods Factors that commonly contribute to health inequalities and included in this review were: (i) Protected characteristics (age, ethnicity, disability, gender, sexual orientation); (ii) Socio-economic characteristics (employment status, deprivation, education, income, insurance); (iii) Vulnerable groups (migration status, sex workers, people who inject drugs (PWID), the homeless); (iv) Geography (region, urban or rural dwelling). The PRISMA-ScR was followed. Systematic literature searches were performed on OVID Embase and Medline and included published papers between January 2010 and April 2021. Exclusion criteria were research undertaken in low- or middle-income countries, viral (including COVID-19) and fungal infections and tuberculosis. Regular co-author meetings provided second checking of extracted data. Results Antibiotic use: Fifty-eight of 402 papers were included; most were from the USA (n=34) followed by the UK (n=12). Fifty papers focused on one or more protected characteristics, 37 on socio-economic characteristics, 21 on geography and 6 on migration status. Sample findings: In England, areas of high deprivation had increased antibiotic prescribing, with most deprived areas showing increased rates of broad-spectrum antibiotic use. In the USA, patients from rural areas were more likely to have nitrofurantoin for urinary tract infections inappropriately prescribed compared to urban dwellers. Antibiotic-resistant infections: Ten of 137 papers were included; the majority from the USA (n=6). Six papers focused on ethnicity, three on age and one each on deprivation, income, migration status, PWID and geography. Sample findings: In the USA, African American and Hispanic patients had higher rates of methicillin-resistant Staphylococcus aureus (MRSA) compared to patients of other ethnicities. Immigrants had lower rates of MRSA infections, but higher rates of methicillin-susceptible S. aureus wound infections, compared to USA-born citizens. Across Europe, E. coli infections resistant to aminoglycosides had strong association with income inequality. Discussion/Conclusion There is evidence for an association between health inequalities and antibiotic use, and health inequalities and risk of antibiotic-resistant infections. Further research is needed to understand how differences in antibiotic use affect AMR spread amongst populations. A study limitation includes addressing each health inequality individually without investigating how they may interact together to affect antibiotic use and infection resistance patterns. A strength is use of the PRISMA-ScR reporting guideline and systematic literature search. The pharmacy profession is trusted by the public3 and ideally placed in community and hospital settings to raise awareness of how health inequalities impact infection management and resistance rates, as well as advocate for equity of access in Core20PLUS populations. References 1. National Institute for Health and Care Excellence, Community pharmacies: promoting health and wellbeing. 2018: https://www.nice.org.uk/guidance/ng102/chapter/Recommendations 2. O'Hare A, Harvey E, and Ashiru-Oredope D. Patient safety spotlight: how pharmacy teams can help minimise antimicrobial resistance. Regulate. 2022 3. Crossley, K. Public perceives pharmacists as some of the most trusted professionals. Pharmacy Times. 2019;18

Introduction Antimicrobial intravenous-to-oral switch (IVOS) is an antimicrobial stewardship (AMS) strategy with patient safety and cost-effectiveness benefits. Studies show that IVOS decisions had no negative impact on patient outcomes,1 and pharmacist involvement brought about more appropriate antibiotic prescribing and 34% reduction in medication costs.2 Healthcare settings have developed individualised local IVOS checklists. Aim To collate IVOS criteria from local checklists, complete a rapid literature review to evaluate IVOS criteria and undertake a 3-step Delphi consensus-gathering process to agree evidence-based, UK-wide IVOS criteria for hospitalised adults. Methods Local IVOS checklists from the UK nations were sought through stratified sampling. The rapid review followed PRISMA guidance and is registered on PROSPERO [CRD42022320343]. Criteria with highest, or over 50%, appearance in checklists and literature were combined for Step 1 of the 3-step Delphi process. Step 1: Pilot/1st round questionnaire: An expert panel appraised each criterion via a 5-point Likert scale for relevance to safe and effective IVOS and ease of assessment in the clinical setting. Step 2: Virtual meeting: Step 1 respondents discussed questionnaire results and attained criteria consensus for Step 3. Step 3: 2nd round questionnaire: Healthcare professionals UK-wide stated level of agreement via a 5-point Likert scale regarding the need of each criterion for safe and effective IVOS. Results Forty-five local IVOS checklists were selected: 42 from English Acute Trusts, two from Scottish Health Boards and the All-Wales checklist. Sixteen of 477 papers were included in the rapid review. Criteria were synthesised into a 5-section framework: 1-Timing of IV antimicrobial review; 2-Clinical signs and symptoms; 3-Infection markers; 4-Enteral route; 5-Infection exclusions. Combination of IVOS criteria resulted in 41 criteria for Step 1. Step 1 had 24 respondents, 15 of those participated in Step 2. Thirty-five criteria went into Step 3, which had 242 respondents (England n=195, Northern Ireland n=18, Scotland n=18, Wales n=11). The majority were female (n=154; n=7 preferred not to say) and based in NHS Acute Teaching Trusts (n=121). Antimicrobial or infection specialist pharmacists were the highest respondents (n=65) followed by general physicians (n=55). Sixty-seven per cent of respondents (n=161) considered IVOS to have a positive impact on outcomes of clinically stable patients. Consensus was achieved for 27 IVOS criteria (66% of initial criteria). Examples of agreed criteria were: ‘IVOS should be considered within 48 hours of first dose of IV antimicrobial being administered’ and ‘Temperature between 36-38°C for past 24 hours’. Discussion/Conclusion Evidence-based consensus was achieved for IVOS criteria from a UK-wide multidisciplinary group and will be used to develop an IVOS tool for hospitalised adults. A study strength was use of the Delphi process to capture consensus; a limitation was no checklist from Northern Ireland was identified at time of the study, however Steps 1-3 had participation from Northern Ireland. Early IVOS initiatives led by ward pharmacists have previously been shown to reduce use of hospital intravenous broad-spectrum antibiotics: co-amoxiclav (-27.9%) and cefuroxime (-46.5%).3 Further research is needed to operationalise the nationally agreed criteria in UK hospitals, expand AMS roles of pharmacy and nursing teams and assess impact. References 1. Wongkamhla T, Khan-Asa B, Tongsai S, Angkasekwinai N. Infectious Disease Team Review Using Antibiotic Switch and Discharge Criteria Shortens the Duration of Intravenous Antibiotic: A Single-Center Cluster-Randomized Controlled Trial in Thailand. Open Forum Infect Dis. 2020;7(12):ofaa539. 2. Polidori P, Leonardi Vinci D, Adami S, Bianchi S, Faggiano ME, Provenzani A. Role of the hospital pharmacist in an Italian antimicrobial stewardship programme. Eur J Hosp Pharm. 2021;29:95-100. 3. Sze WT, Kong MC. Impact of printed antimicrobial stewardship recommendations on early intravenous to oral antibiotics switch practice in district hospitals. Pharm Pract. 2018;16(2):855.