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Background: ESBL-producing Enterobacteriaceae (ESBLPE) are increasing in prevalence worldwide and are more difficult to treat than non-ESBLPE. Their prevalence in the UK general population is unknown, as the only previous UK ESBLPE faecal colonization study involved patients with diarrhoea.Objectives: To estimate the prevalence of CTX-M ESBLPE faecal colonization in the general adult population of England in 2014, and investigate risk factors.Methods: A stratified random sample of 58 337 registered patients from 16 general practices within four areas of England were invited to participate by returning faeces specimens and self-completed questionnaires. Specimens were tested for ESBLPE and carbapenemase-producing Enterobacteriaceae (CPE).Results: 2430 individuals participated (4% of those invited). The estimated prevalence of colonization with CTX-M ESBLPE in England was 7.3% (95% CI 5.6%-9.4%) (Shropshire 774 participants, 4.9% colonization; Southampton City 740 participants, 9.2%; Newham 612 participants, 12.7%; Heart of Birmingham 234 individuals, 16.0%) and was particularly high in: those born in Afghanistan (10 participants, 60.0% colonization, 95% CI 29.7%-84.2%); those born on the Indian subcontinent (India, Pakistan, Bangladesh or Sri Lanka) (259 participants, 25.0% colonization, 95% CI 18.5%-32.9%); travellers to South Asia (India, Pakistan, Bangladesh, Sri Lanka or Nepal) in the last year (140 participants, 38.5% colonization, 95% CI 27.8%-50.5%); and healthcare domestics (8 participants, unweighted 37.5% colonization, 95% CI 8.5%-75.5%). Risk factors identified included: being born in the Indian subcontinent (aOR 5.4, 95% CI 3.0-9.7); travel to South Asia (aOR 2.9, 95% CI 1.8-4.8) or to Africa, China, South or Central America, South East or Pacific Asia or Afghanistan (aOR 2.6, 95% CI 1.7-4.1) in the last year; and working as a healthcare domestic (aOR 6.2, 95% CI 1.3-31). None of the 48 participants who took co-amoxiclav in the last year was colonized with CTX-M ESBLPE. blaCTX-M-15 accounted for 66% of CTX-M ESBLPE positives. 0.1% (two participants) were colonized with CPE.Conclusions: CTX-M ESBLPE are established in the general population in England and prevalence is particularly high in people from certain countries of birth or with recent travel. We recommend that these findings be taken into account in guidance on the empirical management of patients presenting with a likely Enterobacteriaceae infection. [ABSTRACT FROM AUTHOR]

Background Repeat infection with gonorrhoea may contribute significantly to infection persistence and health service workload. The authors investigated whether repeat infection is associated with particular subgroups who may benefit from tailored interventions. Methods Data on gonorrhoea diagnoses between 2004 and 2008 were obtained from Sheffield sexually transmitted infection clinic. Kaplane--Meier survival curves were used to estimate the percentage of patients with repeat diagnoses within a year, and a Cox proportional hazard model was used to investigate associated risk factors. Results Of 1650 patients diagnosed with gonorrhoea, 7.7% (95% CI 6.5% to 9.1%) had a repeat diagnosis within 1 year. Men who have sex with men under 30, teenage heterosexuals, black Caribbeans, people living in deprived areas and those diagnosed in 2004 were most likely to represent. Of those patients (53%) providing additional behavioural data, repeat diagnosis was more common in those reporting prior history of gonorrhoea, any previous sexually transmitted infection diagnoses, two or more partners in the past 3 months and a high- risk partner in the past year. In an adjusted analysis, repeat diagnosis was independently associated with being a young man who has sex with men, living in a deprived area, a history of gonorrhoea and being diagnosed in 2004 but was most strongly associated with non-completion of behavioural data forms. Conclusions Groups most at risk of repeat infection with gonorrhoea are highly predictable but are disinclined to provide detailed information on their sexual behaviour. Care pathways including targeted and intensive one-to-one risk reduction counselling, effective partner notification and offers of re-testing could deliver considerable public health benefit. [ABSTRACT FROM AUTHOR]

Objectives The third-generation cephalosporins recommended in national guidelines are amongst the last remaining effective agents for treatment of gonorrhoea. This study characterizes gonococcal isolates with decreased cefixime susceptibility from England and Wales. Methods A total of 96 isolates of Neisseria gonorrhoeae exhibiting cefixime MICs of ≥0.125 mg/L, either collected as part of the Gonococcal Resistance to Antimicrobials Surveillance Programme (GRASP) between 2005 and 2008 (54 from a total of 4649 isolates) or referred to the national reference laboratory in 2008 and 2009 (42 isolates), were tested for susceptibility to a range of antimicrobial agents and were typed using N. gonorrhoeae multiantigen sequence typing (NG-MAST). Results All 96 isolates were also resistant to tetracycline (MIC ≥2 mg/L) and ciprofloxacin (MIC ≥16 mg/L) and 56% showed low-level chromosomal resistance to penicillin. Where data were available, the mean patient age was 31 years, and 88% (83/94) of patients were men. Isolates referred through GRASP were predominantly from men who have sex with men (MSM; 29/44, 66%) and from patients of white British ethnicity (25/43, 58%). The majority of isolates belonged either to sequence type (ST) 1407 (71/96, 74%) or to a highly related ST that shares the tpbB allele (allele 110), but with a different por allele (20/96, 21%). ST1407 was found in both MSM (22/29, 76%) and heterosexual patients (12/15, 80%) and among all eight isolates from patients reporting sex abroad. Conclusions The emergence of a clonal group of gonococci showing decreased susceptibility to cefixime in England and Wales highlights the need for continued surveillance. [ABSTRACT FROM PUBLISHER]

Background: In England, screening for genital chlamydial infection has begun; however, screening frequency for women is not yet determined. Aim: To measure chlamydia incidence and reinfection rates among young women to suggest screening intervals. Methods: An 18-month prospective cohort study of women aged 16-24 years recruited from general practices, family planning clinics and genitourinary medicine (GUM) clinics: baseline-negative women followed for incidence and baseline-positive women for reinfection; urine tested every 6 months via nucleic acid amplification; and behavioural data collected. Extra test and questionnaire completed 3 months after initial positive test. Factors associated with infection and reinfection investigated using Cox regression stratified by healthcare setting of recruitment. Results: Chlamydia incidence was mean (95% CI) 4.9 (2.7 to 8.8) per 100 person-years (py) among women recruited from general practices, 6.4 (4.2 to 9.8) from family planning clinics and 10.6 (7.4 to 15.2) from GUM clinics. Incidence was associated with young age, history of chlamydial infection and acquisition of new sexual partners. if recently acquiring new partners, condom use at last sexual intercourse was independently associated with lower incidence. Chlamydia reinfection was mean (95% CI) 29.9 (19.7 to 45.4) per 100/person-year from general practices, 22.3 (15.6 to 31.8) from family planning clinics and 21 .1(14.3 to 30.9) from GUM clinics. Factors independently associated with higher reinfection rates were acquisition of new partners and failure to treat all partners. Conclusions: Sexual behaviours determined incidence and reinfection, regardless of healthcare setting. Our results suggest annual screening of women aged 16-24 years who are chlamydia negative, or sooner if partner change occurs. Rescreening chlamydia-positive women within 6 months of baseline infection may be sensible, especially if partner change occurs or all partners are not treated. [ABSTRACT FROM AUTHOR]

Details a study which examined the laboratory reports of human infection with Cryptosporidium for evidence of changes that have occurred during the 2001 epidemic of foot and mouth disease in England and Wales. Methodology of the study; Age distribution for persons with reported cryptosporidiosis; Prevalence of cryptosporidium; Impact of foot and mouth epidemic on cryptosporidium infection in humans.

In January-March 2013 in England, confirmed measles cases increased in children aged 10-16 years. In April-September 2013, the National Health System and Public Health England launched a national measles-mumps-rubella (MMR) campaign based on data from Child Health Information Systems (CHIS) estimating that approximately 8% in this age group were unvaccinated. We estimated coverage at baseline, and, of those unvaccinated (target), the proportion vaccinated up to 20/08/2013 (mid-point) to inform further public health action. We selected a sample of 6644 children aged 10-16 years using multistage sampling from those reported unvaccinated in CHIS at baseline and validated their records against GP records. We adjusted the CHIS MMR vaccine coverage estimates correcting by the proportion of vaccinated children obtained through sample validation. We validated 5179/6644 (78%) of the sample records. Coverage at baseline was estimated as 94.7% (95% confidence intervals, CI: 93.5-96.0%), lower in London (86.9%, 95%CI: 83.0-90.9%) than outside (96.1%, 95%CI 95.5-96.8%). The campaign reached 10.8% (95%CI: 7.0-14.6%) of the target population, lower in London (7.1%, 95%CI: 4.9-9.3) than in the rest of England (11.4%, 95%CI: 7.0-15.9%). Coverage increased by 0.5% up to 95.3% (95% CI: 94.1-96.4%) but an estimated 210,000 10-16 year old children remained unvaccinated nationally. Baseline MMR coverage was higher than previously reported and was estimated to have reached the 95% campaign objective at midpoint. Eleven per cent of the target population were vaccinated during the campaign, and may be underestimated, especially in London. No further national campaigns are needed but targeted local vaccination activities should be considered. [ABSTRACT FROM AUTHOR]

The article discusses the study which examines the prevalence of human papillomavirus (HPV) antibodies in males and females in England. The researchers have tested the specific HPV antibodies using a multiplexed competitive Luminex assay and have analyzed the seropositivity and geometric mean titers. The study implies that HPV antibody titers do not decline with age, but lower seroprevalence in older females may reflect the changes in their sexual behaviors.

Objectives: Chlamydia prevalence in the general population is a potential outcome measure for the evaluation of chlamydia control programmes. We carried out a pilot study to determine the feasibility of using a postal survey for population-based chlamydia prevalence monitoring., Methods: Postal invitations were sent to a random sample of 2000 17-year-old to 18-year-old women registered with a general practitioner in two pilot areas in England. Recipients were randomised to receive either a self-sampling kit (n=1000), a self-sampling kit and offer of £5 voucher on return of sample (n=500) or a self-sampling kit on request (n=500). Participants returned a questionnaire and self-taken vulvovaginal swab sample for unlinked anonymous Chlamydia trachomatis testing. Non-responders were sent a reminder letter 3 weeks after initial invitation. We calculated the participation rate (number of samples returned/number of invitations sent) and cost per sample returned (including cost of consumables and postage) in each group., Results: A total of 155/2000 (7.8%) samples were returned with consent for testing. Participation rates varied by invitation group: 7.8% in the group who were provided with a self-sampling kit, 14% in the group who were also offered a voucher and 1.0% in the group who were not sent a kit. The cost per sample received was lowest (£36) in the group who were offered both a kit and a voucher., Conclusions: The piloted survey methodology achieved low participation rates. This approach is not suitable for population-based monitoring of chlamydia prevalence among young women in England., Study Registration Number: (UKCRN ID 10913)., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Respiratory tract infection (RTI) is the commonest indication for community antibiotic prescriptions. Prescribing is rising and is influenced by patients' consulting behaviour and beliefs., Aim: To build up a profile of the 'RTI clinical iceberg' by exploring how the general public manage RTI, visit GPs and why., Design and Setting: Two-phase qualitative and quantitative study in England., Method: Qualitative interviews with 17 participants with acute RTI visiting pharmacies in England, and face-to-face questionnaire survey of 1767 adults ≥15 years in households in England during January 2011., Results: Qualitative interviews: interviewees with RTI visited GPs if they considered their symptoms were prolonged, or severe enough to cause pain, or interfered with daily activities or sleep. Questionnaire: 58% reported having had an RTI in the previous 6 months, and 19.7% (95% CI = 16.8 to 22.9%) of these contacted or visited their GP surgery for this, most commonly because 'the symptoms were severe'; or 'after several days the symptoms hadn't improved'; 10.3% of those experiencing an RTI (or 53.1% of those contacting their GP about it) expected an antibiotic prescription. Responders were more likely to believe antibiotics would be effective for a cough with green rather than clear phlegm. Perceptions of side effects of antibiotics did not influence expectations for antibiotics. Almost all who reported asking for an antibiotic were prescribed one, but 25% did not finish them., Conclusion: One-fifth of those with an RTI contact their GP and most who ask for antibiotics are prescribed them. A better public understanding about the lack of benefit of antibiotics for most RTIs and addressing concerns about illness duration and severity, could reduce GP consultations and antibiotic prescriptions for RTI.

Background: Gonorrhoea can rapidly develop resistance to antimicrobials and treatment options are becoming depleted. Treatment guidelines require robust estimates of the prevalence of resistance but sentinel surveillance systems may not be representative nationally., Objective: To investigate the effectiveness of the sentinel Gonococcal Resistance to Antimicrobials Surveillance System (GRASP) at estimating resistance prevalence in England and Wales., Methods: Annual cross-sectional data on reported gonorrhoea diagnoses between 2000 and 2008 were compared between GRASP (26 clinics) and national mandatory (KC60) reporting (229 clinics). Resistance prevalence estimates in GRASP were weighted according to the national distribution of relevant, Patient Characteristics: age group, gender, sexual orientation and geographical region. Trends in actual and weighted estimates were plotted. Results Gonorrhoea cases reported through GRASP were more likely to be from London and to be men who have sex with men (MSM) and were less likely to be women and heterosexual men than those reported through KC60. Weighting for national distributions of demographic characteristics reduced estimates of resistance prevalence, particularly ciprofloxacin in 2006 (27% to 21%). Emerging resistance to cefixime in 2008 was reduced from 1.5% to 1.0%. Weighting did not adjust resistance prevalence above or below the 5% threshold for any antimicrobial., Conclusions: Although over-representing MSM and under-representing women and heterosexual men, GRASP has provided reliable estimates of resistance prevalence in England and Wales. However, weighting for the national distribution of patient characteristics should be considered in future. As resistance usually emerges in MSM, enhanced surveillance of high-risk populations could enable development of more tailored (and therefore optimal) treatment strategies.

Background: Gonorrhoea has been among the easiest infections to cure with antibiotics. Nevertheless, emerging resistance has driven repeated treatment shifts. Decreased cephalosporin susceptibility is now being reported. We examined cephalosporin MIC trends for Neisseria gonorrhoeae in the UK and undertook pharmacodynamic analyses to predict efficacy against strains with raised MICs., Methods: Neisseria gonorrhoeae isolates were collected annually in a structured surveillance from 26 genitourinary medicine clinics in England and Wales. MICs were determined by agar dilution and confirmed by Etests. Pharmacodynamic modelling was performed for cefixime and ceftriaxone with Monte Carlo simulations., Results: There was a progressive emergence of small numbers of gonococci with cephalosporin MICs of 0.125-0.25 mg/L; these were not seen before 2005 but, for ceftriaxone and cefixime, respectively, accounted for 0.4% (95% confidence interval 0.2%-1.1%) and 2.8% (1.6%-4.8%) of the 1253 isolates collected in 2008; such MICs are 16-64 times the modal values for the species. Pharmacodynamic analysis was complicated by evidence that cephalosporins need a longer period with the free drug level above MIC than the 7-10 h required for penicillin G; nevertheless, pharmacodynamic analyses predict that failures with the standard 400 mg cefixime po and 250 mg ceftriaxone im regimens become likely around the present MIC maxima., Conclusions: Gonococci with ceftriaxone and cefixime MICs of 0.125-0.25 mg/L are accumulating in the UK. These MICs lie on the edge of likely responsiveness to current regimens, which need review. Possible responses include: (i) higher cephalosporin doses; (ii) multidose cephalosporin regimens; (iii) multidrug regimens; (iv) microbiologically directed treatment; or, in the future, (v) drug cycling. The practicalities of these approaches are discussed.

Objectives: To determine the effect of the 2008 English public antibiotic campaigns., Methods: English and Scottish (acting as controls) adults aged > or = 15 years were questioned face to face about their attitudes to and use of antibiotics, in January 2008 (1888) before and in January 2009 (1830) after the antibiotic campaigns., Results: Among English respondents, there was a small increase in recollection of campaign posters (2009 23.7% versus 2008 19.2%; P = 0.03), but this increase was only 2.3% higher in England than in Scotland. We did not detect any improvement in either England or Scotland, or any differences between England and Scotland in the understanding of the lack of benefit of antibiotics for coughs and colds, and we found no improvement in antibiotic use. We detected a significant increase in respondents retaining leftover antibiotics. Over 20% reported discussing antibiotics with their general practitioner (GP) or nurse in the year to January 2009. The offer of a delayed antibiotic prescription was reported significantly more often by English respondents (19% versus 8% Scottish in 2009; P = 0.01), and English respondents were advised to use other remedies for coughs and colds significantly more often in the year to January 2009 (12.7% in 2009 versus 7.4% in 2008; P < 0.001)., Conclusions: There is little evidence that the 2008 public antibiotic campaigns were effective. The use and visibility of future campaign materials needs auditing. A carefully planned approach that targets the public in GP waiting rooms and through clinicians in consultations may be a more effective way of improving prudent antibiotic use.

Objectives: To estimate the prevalence of body piercing, other than of earlobes, in the general adult population in England, and to describe the distribution of body piercing by age group, sex, social class, anatomical site, and who performed the piercings. To estimate the proportion of piercings that resulted in complications and the proportion of piercings that resulted in professional help being sought after the piercing., Design: Cross sectional household survey., Setting: All regions of England 2005., Participants: 10,503 adults aged 16 and over identified with a two stage selection process: random selection of geographical areas and filling predefined quotas of individuals. Results weighted to reflect the national demographic profile of adults aged 16 and over., Main Outcome Measures: Estimates of the prevalence of body piercing overall and by age group, sex, and anatomical site. Estimates, in those aged 16-24, of the proportion of piercings associated with complications and the seeking of professional help., Results: The prevalence of body piercing was 1049/10,503 (10%, 95% confidence interval 9.4% to 10.6%). Body piercing was more common in women than in men and in younger age groups. Nearly half the women aged 16-24 reported having had a piercing (305/659, 46.2%, 42.0% to 50.5%). Of the 754 piercings in those aged 16-24, complications were reported with 233 (31.0%, 26.8% to 35.5%); professional help was sought with 115 (15.2%, 11.8% to 19.5%); and hospital admission was required with seven (0.9%, 0.3% to 3.2%)., Conclusions: Body piercing is common in adults in England, particularly in young women. Problems are common and the assistance of health services is often required. Though serious complications requiring admission to hospital seem uncommon, the popularity of the practice might place a substantial burden on health services.

Background: In England, screening for genital chlamydial infection has begun; however, screening frequency for women is not yet determined., Aim: To measure chlamydia incidence and reinfection rates among young women to suggest screening intervals., Methods: An 18-month prospective cohort study of women aged 16-24 years recruited from general practices, family planning clinics and genitourinary medicine (GUM) clinics: baseline-negative women followed for incidence and baseline-positive women for reinfection; urine tested every 6 months via nucleic acid amplification; and behavioural data collected. Extra test and questionnaire completed 3 months after initial positive test. Factors associated with infection and reinfection investigated using Cox regression stratified by healthcare setting of recruitment., Results: Chlamydia incidence was mean (95% CI) 4.9 (2.7 to 8.8) per 100 person-years (py) among women recruited from general practices, 6.4 (4.2 to 9.8) from family planning clinics and 10.6 (7.4 to 15.2) from GUM clinics. Incidence was associated with young age, history of chlamydial infection and acquisition of new sexual partners. If recently acquiring new partners, condom use at last sexual intercourse was independently associated with lower incidence. Chlamydia reinfection was mean (95% CI) 29.9 (19.7 to 45.4) per 100/person-year from general practices, 22.3 (15.6 to 31.8) from family planning clinics and 21.1 (14.3 to 30.9) from GUM clinics. Factors independently associated with higher reinfection rates were acquisition of new partners and failure to treat all partners., Conclusions: Sexual behaviours determined incidence and reinfection, regardless of healthcare setting. Our results suggest annual screening of women aged 16-24 years who are chlamydia negative, or sooner if partner change occurs. Rescreening chlamydia-positive women within 6 months of baseline infection may be sensible, especially if partner change occurs or all partners are not treated.

Objectives: To assess the public's knowledge and attitudes to antibiotics, their reported antibiotic use and the relationship between them., Patients and Methods: A questionnaire was included in the face-to-face Office for National Statistics Omnibus Household Survey in Britain in 2003. Of 10 981 randomly selected adults from England, Scotland and Wales, 7120 (65%) completed the questionnaire., Results: Although 79% of respondents were aware that 'antibiotic resistance is a problem in British hospitals', 38% of respondents did not know that antibiotics do not work against most coughs or colds and 43% did not know that 'antibiotics can kill the bacteria that normally live on the skin and in the gut'. Respondents with lower educational qualifications were less knowledgeable about antibiotics. In a multivariable analysis, better knowledge of antibiotics was not associated with being less likely to be prescribed any in the last year, but was independently associated with being more likely to finish a course of antibiotic as prescribed. Knowledge was also associated with being more likely to take antibiotics without being told to do so. In women, better knowledge was associated with being more likely to give an antibiotic to someone else that was not prescribed for them., Conclusions: We have shown that there is no simple relationship between increased knowledge and more prudent antibiotic use. Future national antibiotic campaigns should have a defined audience and aims in order to facilitate prudent antibiotic use by clinicians and public.

A small national study was carried out in England in 2003/2004 to ascertain the views of primary care trusts (PCTs) and general practitioners (GPs) on whether influenza immunisation should be extended to all people aged 50-64 years from the current recommendation of 65 years or more. Results showed that as many primary care trusts would be in favour, as would not be in favour. A similarly divided view was expressed by general practitioners. Vaccine uptake rates for high-risk (HR) and low-risk (LR) adults aged 50-64 years in the study population were higher in those practices where the GP was in favour of a more inclusive policy of offering flu vaccine to all persons aged 50 years or more, compared with those that did not favour this policy (60% versus 54% HR (p=0.02) and 16% versus 11% LR (p=0.02)). Higher rates of vaccine uptake for low-risk patients aged 50-64 years were also reported from practices where GPs perceived a greater health benefit of immunisation for this age group. Although policy for recommending vaccine to all patients aged 50 years or more is established elsewhere, opinion on whether such a policy should be adopted in England is currently divided amongst those providing local health services.

To improve estimates of disease incidence and deaths from pneumococcal meningitis among adults in England, we performed a capture-recapture analysis for 1996 through 1999. We compared data from Hospital Episode Statistics (HES) and the Public Health Laboratory Services (PHLS) for incidence estimates and from HES and the Office for National Statistics (ONS) for estimates of deaths. Estimated sensitivities for the examined systems were 46% (95% confidence interval [CI] 42% to 50%) for HES and 40% [95% CI 37% to 44%] for PHLS. Sensitivities for mortality rates were found to be similar, 48% [95% CI 41% to 55%] for HES and 49% [95% CI 42% to 56%] for ONS. Stratification analysis showed that the sensitivity in those >85 years of age was significantly lower than the sensitivity for other ages. The estimated case-fatality rate was 24% [95% CI 21% to 26%]. These estimates indicate that a cost-benefit analysis of adult pneumococcal vaccination programs is required.

Objectives: To assess ciprofloxacin resistance among Escherichia coli isolates from bacteraemia patients in England in relation to age, sex and Region., Methods: Routine susceptibility data for bacteraemia isolates were collected from over 90% of hospitals in England., Results: During 1995-2001, the prevalence of ciprofloxacin resistance trebled, from 2.1% to 6.5%. Isolates from men were more frequently resistant than those from women, possibly because infections in men more often involve nosocomial strains. Resistance was rare (<1.5%) in isolates from patients aged <1 year; among older patients, resistance was unrelated to age in isolates from women, but peaked in the 15-44 age group for men., Conclusions: The prevalence of ciprofloxacin resistance in E. coli from bacteraemia is strongly associated with sex and, to a lesser extent, age.

The Gonococcal Resistance to Antimicrobials Surveillance Programme (GRASP) monitors trends in antimicrobial resistance in consecutive gonococcal isolates from 26 genitourinary medicine clinics in England and Wales. In 2002, 2204 gonococcal isolates were tested, and the overall prevalence of ciprofloxacin resistance (minimum inhibitory concentration > or =1 mg/L) was 9.8%, compared with 3.1% in 2001 and 2.1% in 2000. Between 2001 and 2002, prevalence of ciprofloxacin resistance increased two to three-fold, irrespective of recent sexual contact overseas, sex, or residence within or outside of London. These findings suggest that national and local treatment guidelines need to be reviewed urgently.