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Background. The COVID-19 pandemic disproportionately affected people living and working in UK care homes causing high mortality rates. Vaccinating staff members and residents is considered the most effective intervention to reduce infection and its transmission rates. However, uptake of the first dose of the COVID-19 vaccine in care homes was variable. We sought to investigate factors influencing uptake of COVID-19 vaccination in care home staff to inform strategies to increase vaccination uptake and inform future preparedness. Methods. Twenty care home staff including managerial and administrative staff, nurses, healthcare practitioners and support staff from nine care homes across England participated in semi-structured telephone interviews (March-June 2021) exploring attitudes towards the COVID-19 vaccine and factors influencing uptake. We used thematic analysis to generate themes which were subsequently deductively mapped to the Capability, Opportunity, Motivation-Behaviour (COM-B) model. The Behavioural Change Wheel (BCW) was used to identify potential intervention strategies to address identified influences. Results. Enablers to vaccine uptake included the willingness to protect care home residents, staff and family/friends from infection and the belief that vaccination provided a way back to normality (reflective motivation); convenience of vaccination and access to accurate information (physical opportunity); and a supporting social environment around them favouring vaccination (social opportunity). Barriers included fears about side-effects (automatic motivation); a lack of trust due to the quick release of the vaccine (reflective motivation); and feeling pressurised to accept vaccination if mandatory (automatic motivation). Conclusions We identified influences on COVID-19 vaccine uptake by care home staff that can inform the implementation of future vaccination programmes. Strategies likely to support uptake include information campaigns and facilitating communication between staff and managers to openly discuss concerns regarding possible vaccination side effects. Freedom of choice played an important role in the decision to be vaccinated suggesting that the decision to mandate vaccination may have unintended behavioural consequences.

Introduction In secondary care, antimicrobial use (AMU) must be monitored to reduce the risk of antimicrobial resistance and infection-related complications. However, there is variation in how hospitals address this challenge, partly driven by each site’s level of digital maturity, expertise and resources available. This systematic review investigated approaches to measuring AMU to explore how these structural differences may present barriers to engagement with AMU surveillance. Methods We searched four digital databases and the websites of relevant organizations for studies in high-income, inpatient hospital settings that estimated AMU in adults. Excluded studies focused exclusively on antiviral or antifungal therapies. Data were extracted data on 12 fields (study description, data sources, data extraction methods and professionals involved in surveillance). Proportions were estimated with 95% CIs. Results We identified 145 reports of antimicrobial surveillance from Europe (63), North America (53), Oceania (14), Asia (13) and across more than continent (2) between 1977 and 2018. Of 145 studies, 47 carried out surveillance based on digital data sources. In regions with access to electronic patient records, 26/47 studies employed manual methods to extract the data. The majority of identified professionals involved in these studies were clinically trained (87/93). Conclusions Even in regions with access to electronic datasets, hospitals rely on manual data extraction for this work. Data extraction is undertaken by healthcare professionals, who may have conflicting priorities. Reducing barriers to engagement in AMU surveillance requires investment in methods, resources and training so that hospitals can extract and analyse data already contained within electronic patient records.

Background Optimizing antimicrobial use (AMU) is key to reducing antimicrobial-resistant infections, but current AMU monitoring in hospital provides limited insights for quality improvement. Objectives To understand stakeholders’ priorities for developing national AMU surveillance in English hospitals to serve the needs of national policy makers and front-line practitioners. Methods Characteristics of existing AMU surveillance systems were identified from a previous systematic review and categorized by the Acceptability, Practicability, Effectiveness, Affordability, Side-effects and Equity (APEASE) criteria. Stakeholders prioritized characteristics using a two-round RAND-modified Delphi (rating round 1, telephone panel discussion, rating round 2). Findings informed the design of a framework used to assess the extent to which existing surveillance approaches meet stakeholders’ needs. Results Between 17/09/19 and 01/11/19, 24 stakeholders with national and local roles related to AMU prioritized 23 characteristics of AMU surveillance describing: resource for surveillance, data collection, data availability and pathways to translate information from surveillance into practice. No existing surveillance approaches demonstrated all prioritized characteristics. The most common limitation was failure to facilitate clinician engagement with AMU through delays in data access and/or limited availability of disaggregated metrics of prescribing. Conclusions Current surveillance delivers national public health priorities but improving stewardship demands patient-level data linked to clinical outcomes. This study offers a framework to develop current surveillance to meet the needs of local stakeholders in England. Increased investment in data infrastructure and training is essential to make information held within electronic systems available to front-line clinicians to facilitate quality improvement.

Background In primary care there is uncertainty about which patients with acute exacerbations of COPD (AECOPD) benefit from antibiotics. Objectives To identify which types of COPD patients get the most antibiotics in primary care to support targeted antibiotic stewardship. Methods Observational study of COPD patients using a large English primary care database with 12 month follow-up. We estimated the incidence of and risk factors for antibiotic prescribing relative to the number of AECOPD during follow-up, considering COPD severity, smoking, obesity and comorbidity. Results From 157 practices, 19594 patients were diagnosed with COPD, representing 2.6% of patients and 11.5% of all prescribed antibiotics. Eight hundred and thirty-three (4.5%) patients with severe COPD and frequent AECOPD were prescribed six to nine prescriptions per year and accounted for 13.0% of antibiotics. Individuals with mild to moderate COPD and zero or one AECOPD received one to three prescriptions per year but accounted for 42.5% of all prescriptions. In addition to COPD severity, asthma, chronic heart disease, diabetes, heart failure and influenza vaccination were independently associated with increased antibiotic use. Conclusions Patients with severe COPD have the highest rates of antibiotic prescribing but most antibiotics are prescribed for patients with mild to moderate COPD. Antibiotic stewardship should focus on the dual goals of safely reducing the volume of prescribing in patients with mild to moderate COPD, and optimizing prescribing in patients with severe disease who are at significant risk of drug resistance.

BackgroundHospital antimicrobial stewardship (AMS) programmes are multidisciplinary initiatives to optimize antimicrobial use. Most hospitals depend on time-consuming manual audits to monitor clinicians’ prescribing. But much of the information needed could be sourced from electronic health records (EHRs).ObjectivesTo develop an informatics methodology to analyse characteristics of hospital AMS practice using routine electronic prescribing and laboratory records.MethodsFeasibility study using electronic prescribing, laboratory and clinical coding records from adult patients admitted to six specialities at Queen Elizabeth Hospital, Birmingham, UK (September 2017–August 2018). The study involved: (i) a review of AMS standards of care; (ii) their translation into concepts measurable from commonly available EHRs; and (iii) a pilot application in an EHR cohort study (n = 61679 admissions).ResultsWe developed data modelling methods to characterize antimicrobial use (antimicrobial therapy episode linkage methods, therapy table, therapy changes). Prescriptions were linked into antimicrobial therapy episodes (mean 2.4 prescriptions/episode; mean length of therapy 5.8 days), enabling several actionable findings. For example, 22% of therapy episodes for low-severity community-acquired pneumonia were congruent with prescribing guidelines, with a tendency to use broader-spectrum antibiotics. Analysis of therapy changes revealed IV to oral therapy switching was delayed by an average 3.6 days (95% CI: 3.4–3.7). Microbial cultures were performed prior to treatment initiation in just 22% of antibacterial prescriptions. The proposed methods enabled fine-grained monitoring of AMS practice down to specialities, wards and individual clinical teams by case mix, enabling more meaningful peer comparison.ConclusionsIt is feasible to use hospital EHRs to construct rapid, meaningful measures of prescribing quality with potential to support quality improvement interventions (audit/feedback to prescribers), engagement with front-line clinicians on optimizing prescribing, and AMS impact evaluation studies.

Additional file 1 Table S1. Baseline characteristics and population comparisons. Table S2. Symptom reporting by infection syndrome. Table S3. Age and sex-specific rates of infection syndromes. Table S4. Healthcare-seeking behaviours by type of infection and sex for adults and children. Table S5. Reported types of antibiotics used by infection syndrome. Table S6. Consecutive days of symptom reporting. Table S7. Symptom duration model fitting by model and infection syndrome. Table S8. Age-specific estimates of symptom duration for respiratory infection syndromes. Table S9. Health-related quality of life at baseline. Table S10. Health-related quality of life impacts by infection syndrome. Table S11. Background frequency of symptoms related to novel coronavirus (COVID-19) in Bug Watch cohort by day and month. Figure S1. Identification of incident infection syndromes. Figure S2. Number of complete and incomplete weekly surveys. Figure S3. Inclusion and exclusion of study participants. Figure S4. Infection syndrome incidence by month. Figure S5. Symptom reporting by infection syndrome.

Additional file 4: Sensitivity analysis Table 1. Resident and care home characteristics Table 2. Rates and single variable analysis of antibiotic prescribing by resident and care home characteristics Table 3. Multivariable analysis of antibiotic prescribing

Additional file 3: Country-specific analyses of rates of antibiotic prescribing in care homes Table 1. Care home Table 2. Rates and single variable negative binomial regressioncharacteristics Table 3. Multivariable negative binomial regression

Additional file 2. Characteristics of residents and care homes included and excluded from main analysis

Introduction The purpose of this study was to evaluate whether GPs can support medical students in learning basic neurology in the context of a traditional hospital neurology attachment. Method This was a qualitative evaluation using routinely collected data from stakeholders, consisting of qualitative data in the form of student evaluation questionnaires, course documentation and correspondence from faculty staff. Results The addition of GP teaching to the programme increased availability of patients with neurological problems accessible to students and provided a safe, supportive environment for students to learn their fundamental clinical skills. Students gained valuable insights into the impact of neurological disease from the perspective of patients, their families and carers. GP teaching of neurology was well regarded by students. Some GP tutors felt they lacked adequate experience to teach more technical aspects of neurology, and some students shared this concern. Concepts of professional boundaries between generalists and specialists were not observed, but GP teaching was perceived to be 'other' or outside normal medical school activity. Conclusions General practitioners can successfully facilitate students' access to patients with neurological disease and employ their generalist to enhance neurological learning. Some GPs were initially uncomfortable with teaching skills such as detailed neurological physical examination.

With the aim of populating the Lives Saved Tool (LiST) with parameters of effectiveness of existing interventions, we conducted a systematic review of the literature assessing the effect of pneumonia case management on mortality from childhood pneumonia. This review covered the following interventions: community case management with antibiotic treatment, and hospital treatment with antibiotics, oxygen, zinc and vitamin A. Pneumonia mortality outcomes were sought where available but data were also recorded on secondary outcomes. We summarized results from randomized controlled trials (RCTs), cluster RCTs, quasi-experimental studies and observational studies across outcome measures using standard meta-analysis methods and used a set of standardized rules developed for the purpose of populating the LiST with required parameters, which dealt with the issues of comparability of the studies in a uniform way across a spectrum of childhood conditions. We estimate that community case management of pneumonia could result in a 70% reduction in mortality from pneumonia in 0–5-year-old children. In contrast treatment of pneumonia episodes with zinc and vitamin A is ineffective in reducing pneumonia mortality. There is insufficient evidence to make a quantitative estimate of the effect of hospital case management on pneumonia mortality based on the published data. The available evidence reinforces the effectiveness of community and hospital case management with World Health Organization recommended antibiotics and the lack of effect of zinc and vitamin A supportive treatment for children with pneumonia. Evidence from one trial demonstrates the effectiveness of oxygen therapy but further research is required to give higher quality evidence so that an effect estimate can be incorporated into the LiST model. We identified no trials that separately evaluated the effectiveness of other supportive care interventions. The summary estimates of effect on pneumonia mortality will inform the LiST model. Keywords childhood pneumonia, case management, community, hospital, developing countries