Publications by authors named "Akke Vellinga"

60 Publications

Preventing sepsis; how can artificial intelligence inform the clinical decision-making process? A systematic review.

Int J Med Inform 2021 Apr 10;150:104457. Epub 2021 Apr 10.

School of Pharmacy, Newcastle University, King George VI Building, Newcastle upon Tyne, NE1 7RU, UK. Electronic address:

Background And Objectives: Sepsis is a life-threatening condition that is associated with increased mortality. Artificial intelligence tools can inform clinical decision making by flagging patients at risk of developing infection and subsequent sepsis. This systematic review aims to identify the optimal set of predictors used to train machine learning algorithms to predict the likelihood of an infection and subsequent sepsis.

Methods: This systematic review was registered in PROSPERO database (CRD42020158685). We conducted a systematic literature review across 3 large databases: Medline, Cumulative Index of Nursing and Allied Health Literature, and Embase. Quantitative primary research studies that focused on sepsis prediction associated with bacterial infection in adults in all care settings were eligible for inclusion.

Results: Seventeen articles met our inclusion criteria. We identified 194 predictors that were used to train machine learning algorithms, with 13 predictors used on average across all included studies. The most prevalent predictors included age, gender, smoking, alcohol intake, heart rate, blood pressure, lactate level, cardiovascular disease, endocrine disease, cancer, chronic kidney disease (eGFR<60 mL/min), white blood cell count, liver dysfunction, surgical approach (open or minimally invasive), and pre-operative haematocrit < 30 %. All included studies used artificial intelligence techniques, with average sensitivity 75.7 ± 17.88, and average specificity 63.08 ± 22.01.

Conclusion: The type of predictors influenced the predictive power and predictive timeframe of the developed machine learning algorithm. Predicting the likelihood of sepsis through artificial intelligence can help concentrate finite resources to those patients who are most at risk. Future studies should focus on developing more sensitive and specific algorithms.
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http://dx.doi.org/10.1016/j.ijmedinf.2021.104457DOI Listing
April 2021

Corona citizens' science project-repeated surveys of the Irish response to COVID-19 and subsequent lockdown and restrictive measures.

Ir J Med Sci 2021 Mar 24. Epub 2021 Mar 24.

Insight Centre for Data Analytics National, University of Ireland, Galway, Ireland.

Background: Worldwide, many people have been affected by COVID-19, a novel respiratory illness, caused by a new type of coronavirus SARS-CoV2. The COVID-19 outbreak is considered a pandemic and has created a number of challenges for the general population, patients, and healthcare professionals. Lockdowns have been implemented to slow down the spread of the virus with the expectation that these restrictions will limit the number of cases, and hence the number of hospitalizations and ICU admissions. However, these restrictions, and in particular lockdowns, impact on the life of everyone living in Ireland.

Aim: To record how the COVID-19 pandemic and subsequent restrictive measures impacted on people's activities, work, schooling, and childcare.

Methods: The Corona Citizens' Science Project was set up as a population-wide survey. A questionnaire was designed, and the survey was first launched on the 8th of April 2020. An overview of results was released in the press days later. Data was collected in four waves: April 8, April 22, May 6, and June 17, 2020. Each wave had core questions allowing to compare each wave, and wave-specific questions, to understand current impact of changing measures.

Results: Over four waves, 152,259 responses were collected. The mean age of respondents was 47 with about 10% over the age of 65. Around 75% were female and 85% had a higher degree. Nearly 70% of the respondents were in employment, and around 13% were retired. Up to 20% of the respondents were essential workers, and 10% of respondents indicated they were in receipt of the COVID-19 pandemic unemployment payment. Around 10% of the people who responded were living alone. The number of people talked to the previous day was on average 2.3 in the first survey; during the lockdown, this went up over time, and in the last survey, the mean was 3.9. The percentage of respondents who did not talk to anyone the previous day decreased from 40 to 22% over the waves. In the first wave, about 6% of respondents reported having had flu-like symptoms in the last 14 days, which declined to 3.3%, 2.5%, and 2.0% in waves 2, 3, and 4 respectively. Similarly, over the four waves, the respondents who indicated that someone they lived with had flu-like symptoms declined from 17 to 12%, 9%, and 11%. Throughout the four waves, nearly one third of people reported one or more underlying conditions.

Conclusions: As a result of the COVID-19 pandemic, a number of restrictive measures, in particular lockdown, were implemented in Ireland to protect populations and healthcare systems. To record some of the major impacts on society, we launched a Corona Citizens Science Project, with the aim to support decision-making. This report provides detail of its findings.
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http://dx.doi.org/10.1007/s11845-021-02582-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7988378PMC
March 2021

What discontinued trials teach us about trial registration?

BMC Res Notes 2021 Feb 5;14(1):47. Epub 2021 Feb 5.

Royal College of Surgeons in Ireland, 121/122 St. Stephen's Green, Dublin 2, Ireland.

Objective: Trial registries were set up to improve transparency, remove duplication, improve awareness and avoid waste. Many trials never reach the point of patient enrolment due to a myriad of reasons. The aim of this study was to investigate the reasons for and characteristics of discontinuation of trials.

Results: A total of 163 discontinued trials were identified and compared to completed trials. A Survey was designed to further explore the nature and conduct of the trial. No differences in registered and categorised information was observed between discontinued and completed trials. Most trials discontinue due to patient or participant recruitment issues, often related to funding. Substantial changes to procedures or the protocol or changes to recruitment strategy were also commonly cited reasons. Survey information was available for 21 discontinued and 28 completed trials and no obvious differences could be identified. Our findings highlight the underlying problem of lack of detail, suboptimal recording, dated information and incomplete reporting of trials within a trial registry which hampers sharing and learning. To date, important progress has been made by the implementation of standards and the requirement of trials to be registered. Our review identifies areas where further improvements can be made.
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http://dx.doi.org/10.1186/s13104-020-05391-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7863519PMC
February 2021

Treatment of uncomplicated UTI in males: a systematic review of the literature.

BJGP Open 2021 Apr 26;5(2). Epub 2021 Apr 26.

School of Medicine, National University of Ireland, Galway, Ireland

Background: Urinary tract infections (UTIs) affect around 20% of the male population in their lifetime. The incidence of UTIs in men in the community is 0.9-2.4 cases per 1000 aged <55 years and 7.7 per 1000 aged ≥85 years.

Aim: To evaluate the outcomes of randomised controlled trials (RCTs) comparing the effectiveness of different antimicrobial treatments and durations for uncomplicated UTIs in adult males in outpatient settings.

Method: A systematic literature review of RCTs of adult male patients with an uncomplicated UTI treated with oral antimicrobials in any outpatient setting. The outcomes were symptom resolution within 2 weeks of starting treatment, duration until symptom resolution, clinical cure, bacteriological cure, and frequency of adverse events.

Results: From the 1052 abstracts screened, three provided sufficient information on outcomes. One study compared trimethoprim-sulfamethoxazole for 14 days (21 males) with 42 days (21 males). Fluoroquinolones were compared in the two other RCTs: lomefloxacin (10 males) with norfloxacin (11 males), and ciprofloxacin for 7 days (19 males) and 14 days (19 males). Combining the results from the three RCTs shows that for 75% males with a UTI (76/101) bacteriological cure was reported at the end of the study. Of the 59 patients receiving a fluoroquinolone, 57 (97%) reported bacteriological and clinical cure within 2 weeks after treatment.

Conclusion: The evidence available is insufficient to make any recommendations in relation to type and duration of antimicrobial treatment for male UTIs. Sufficiently powered RCTs are needed to identify best treatment type and duration for male UTIs in primary care.
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http://dx.doi.org/10.3399/bjgpopen20X101140DOI Listing
April 2021

Improving the quality of antibiotic prescribing through an educational intervention delivered through the out-of-hours general practice service in Ireland.

Eur J Gen Pract 2020 Dec;26(1):119-124

School of Medicine, National University of Ireland, Galway, Ireland.

Background: Antibiotic resistance is a threat to our health and health systems. Up to 70% of antibiotics are prescribed in general practice. In Ireland, Out-of-hours (OOH) services are mostly provided by co-operatives of GPs and the 11 main OOH centres cover up to 90% of the population. More than 80% of GPs are involved in OOH care in their area, which provides an opportunity to deliver education and awareness through this centralised system.

Objectives: To analyse the change in the quality of antibiotic prescribing after the introduction of an educational intervention categorising antibiotics into a red (avoid) and green (preferred) panel.

Methods: Educational information for the GP was developed based on the national prescribing guidelines. A particular focus was to reduce co-amoxyclav prescribing. An electronic pop-up message to record whether an antibiotic was prescribed, was displayed at the end of each consultation in the patient management software of the OOH-centre, after the decision of prescribing was made. Antibiotic prescribing was compared for a 13-week period (week 47-week 7) in 2016/2017 with 2017/2018.

Results: Pre-intervention prescribing of red antibiotics was 44% which reduced to 17% after the intervention. The mean percentage of co-amoxyclav, the most prescribed non-firstline prescription, was 33% of all antibiotic prescriptions which dropped to 10%.

Conclusion: Our intervention implemented in the OOH GP service categorised antibiotics into red prescriptions and green (firstline) prescriptions, which was recorded through an electronic pop-up message, resulted in an absolute reduction of 27% in red prescriptions and more than 23% in co-amoxyclav prescriptions.
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http://dx.doi.org/10.1080/13814788.2020.1784137DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7470051PMC
December 2020

The effectiveness of digital multimedia presentation of trial information on recruitment and retention of patients: Protocol for a study within a trial (SWAT).

HRB Open Res 2020 30;3:10. Epub 2020 Mar 30.

HRB Trials Methodology Research Network, National University of Ireland, Galway, Ireland.

Studies within trials (SWATs) present an opportunity to examine design factors that may impact on the successful delivery of trials. One area in need of research is trial recruitment. Recruiting patients to trials is a major challenge facing trialists. Failure to meet recruitment targets can result in delays and underpowered studies. This SWAT evaluates the effectiveness of hand-held digital multimedia presentation of trial information and standard written patient information to potential participants on recruitment and retention to a host trial. : This is the protocol for SWAT 15, a two-group, embedded parallel randomised controlled trial (RCT) (ISRCTN12838042) designed within a host trial - the SATIN trial (ISRCTN88111427), a RCT designed for implementation in the Irish primary care setting. The SWAT eligibility criteria was determined by the host trial. General practices who agree to participate in the host trial will provide women (participants) who are willing to consider participating in the host trial with either a multimedia digital information resource facilitated through a handheld tablet device, plus a written participant information leaflet (Intervention) or a written participant information leaflet (comparator). Outcomes are recruitment and retention to the host SATIN trial and participant's quality of decision-making. : Although designed to be implemented in a host trial, the host trial, was suspended and therefore this SWAT was not implemented. The protocol and the lessons learnt whilst developing it offer guidance to researchers who wish to answer similar research questions in the future in a similar context or setting.   : ISRCTN Registry ISRCTN12838042 (11/10/2017).
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http://dx.doi.org/10.12688/hrbopenres.12994.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7308906PMC
March 2020

GPs' attitudes towards the diagnosis and treatment of male urinary tract infections: a qualitative interview study in Ireland.

BJGP Open 2019 Oct 15. Epub 2019 Oct 15.

Epidemiologist and Senior Lecturer, Health Research Board Primary Care Clinical Trials Network, National University of Ireland, Galway, Ireland.

Background: In general practice, males represent around 20% of the total number of urinary tract infection (UTI) consultations. The majority of UTI research focuses on the diagnosis and treatment of women with UTIs but there is little evidence on how male UTIs are treated.

Aim: To better understand GPs' attitudes towards the diagnosis and treatment of male UTIs. This research aimed to support future investigations to determine best practice in diagnosis and treatment of male UTI.

Design And Setting: A qualitative interview study was carried out with 15 GPs across Ireland.

Method: A topic guide was created to ensure consistency in interviews. The interviews were audiorecorded and transcribed verbatim. Transcripts were analysed using thematic analysis.

Results: Fifteen interviews with GPs were completed. Analysis indicated that GPs' knowledge of guidelines and implementation of them varied widely when deciding a treatment plan for a male presenting with UTI symptoms. There was clear consensus that male UTIs were uncommon and complicated to diagnose. Three GPs reported never treating a male UTI, while others reported treating <5 patients in their careers. There was an assumption that sexually transmitted infections (STI) take precedence in young males when presenting with similar symptoms. The use of antimicrobial treatment guidelines varied widely, in line with the interpretation of the origin and severity of symptoms.

Conclusion: Male UTIs are perceived by GPs as rare and complicated. GPs expressed that patient age, resources, and guidelines available limited their confidence in diagnosing and treating male UTIs.
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http://dx.doi.org/10.3399/bjgpopen19X101667DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6995865PMC
October 2019

Hand Hygiene Compliance in the ICU: A Systematic Review.

Crit Care Med 2019 09;47(9):1251-1257

Irish Centre for Applied Patient Safety and Simulation, School of Medicine, National University of Ireland Galway, Galway, Ireland.

Objectives: To synthesize the literature describing compliance with World Health Organization hand hygiene guidelines in ICUs, to evaluate the quality of extant research, and to examine differences in compliance levels across geographical regions, ICU types, and healthcare worker groups, observation methods, and moments (indications) of hand hygiene.

Data Sources: Electronic searches were conducted in August 2018 using Medline, CINAHL, PsycInfo, Embase, and Web of Science. Reference lists of included studies and related review articles were also screened.

Study Selection: English-language, peer-reviewed studies measuring hand hygiene compliance by healthcare workers in an ICU setting using direct observation guided by the World Health Organization's "Five Moments for Hand Hygiene," published since 2009, were included.

Data Extraction: Information was extracted on study location, research design, type of ICU, healthcare workers, measurement procedures, and compliance levels.

Data Synthesis: Sixty-one studies were included. Most were conducted in high-income countries (60.7%) and in adult ICUs (85.2%). Mean hand hygiene compliance was 59.6%. Compliance levels appeared to differ by geographic region (high-income countries 64.5%, low-income countries 9.1%), type of ICU (neonatal 67.0%, pediatric 41.2%, adult 58.2%), and type of healthcare worker (nursing staff 43.4%, physicians 32.6%, other staff 53.8%).

Conclusions: Mean hand hygiene compliance appears notably lower than international targets. The data collated may offer useful indicators for those evaluating, and seeking to improve, hand hygiene compliance in ICUs internationally.
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http://dx.doi.org/10.1097/CCM.0000000000003868DOI Listing
September 2019

A Mixed-Methods Exploration of the Educational Climate and Safety Climate During the First Year of Clinical Practice in Ireland.

Acad Med 2019 11;94(11):1800-1805

S. Lydon is behavioral psychologist and lecturer in quality and patient safety, School of Medicine, National University of Ireland Galway, Galway, Ireland. D. Byrne is professor of health care simulation, School of Medicine, National University of Ireland Galway, and director of simulation, Saolta University Health Care Group, Galway, Ireland. A. Vellinga is epidemiologist and lecturer in primary care and in bacteriology, School of Medicine, National University of Ireland Galway, Galway, Ireland. C. Walsh is a PhD candidate, Discipline of General Practice, National University of Ireland Galway, Galway, Ireland. C. Madden is a PhD candidate, Discipline of General Practice, National University of Ireland Galway, Galway, Ireland. F. Connolly is research assistant, Department of Health Systems, University College Dublin, Dublin, Ireland. P. O'Connor is human factors psychologist and lecturer in primary care, Discipline of General Practice, National University of Ireland Galway, Galway, Ireland.

Purpose: Educational climate (EC) and safety climate (SC) are key determinants of residents' professional development. The goal of this study was to gather longitudinal EC data and data on perceptions of SC in residency, and provide data on practices related to perceptions of EC and SC, by identifying factors associated with and changes in perceptions of EC and SC across the first year of practice, and elucidating good and poor practice relating to key elements of EC and SC.

Method: A mixed-methods design was adopted. First, 131 first-year residents in Ireland were surveyed at the end of each of their first 3 rotations (August 2016-March 2017). The survey measured EC and SC using established measures. Next, 69 semistructured interviews were conducted with a representative sample of residents (March-May 2017). An interview schedule was developed to aid in-depth probing of EC and SC perceptions. A deductive content analysis approach was adopted.

Results: Perceptions of EC worsened over time. The EC and SC of surgical rotations were significantly poorer than those of medical rotations. Residents were more likely to describe team practices, rather than organizational practices, that contributed positively to their perceptions of EC and SC.

Conclusions: Further research is necessary to facilitate improvement of EC and SC for residents, particularly within surgical training. Future research exploring the contribution of organizational practices to EC and SC, the impact of targeted improvement activities, and best practices for involving residents in quality and safety initiatives is recommended.
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http://dx.doi.org/10.1097/ACM.0000000000002818DOI Listing
November 2019

Meta-analysis of the accuracy of termination of resuscitation rules for out-of-hospital cardiac arrest.

Emerg Med J 2019 Aug 29;36(8):479-484. Epub 2019 May 29.

Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.

Background: Our objective was to perform a systematic review of studies reporting the accuracy of termination of resuscitation rules (TORRs) for out-of-hospital cardiac arrest (OHCA).

Methods: We performed a comprehensive search of the literature for studies evaluating the accuracy of TORRs, with two investigators abstracting relevant data from each study regarding study design, study quality and the accuracy of the TORRs. Bivariate meta-analysis was performed using the mada procedure in R.

Results: We identified 14 studies reporting the performance of 9 separate TORRs. The sensitivity (proportion of eventual survivors for whom the TORR recommends resuscitation and transport) was generally high: 95% for the European Resuscitation Council (ERC) TORR, 97% for the basic life support (BLS) TORR and 99% for the advanced life support (ALS) TORR. The BLS and ERC TORR were more specific, which would lead to fewer futile transports, and all three of these TORRs had a miss rate of ≤0.13% (defined as a case where a patient is recommended for termination but survives). The pooled proportion of patients for whom each rule recommends TOR was much higher for the ERC and BLS TORRs (93.5% and 74.8%, respectively) than for the ALS TORR (29.0%).

Conclusions: The BLS and ERC TORRs identify a large proportion of patients who are candidates for termination of resuscitation following OHCA while having a very low rate of misclassifying eventual survivors (<0.1%). Further prospective validation of the ERC TORR and direct comparison with BLS TORR are needed.
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http://dx.doi.org/10.1136/emermed-2018-207833DOI Listing
August 2019

Role of patient descriptors in predicting antimicrobial resistance in urinary tract infections using a decision tree approach: A retrospective cohort study.

Int J Med Inform 2019 07 24;127:127-133. Epub 2019 Apr 24.

Discipline of General Practice, School of Medicine, National University of Ireland Galway (NUIG), Ireland; Discipline of Bacteriology, School of Medicine, National University of Ireland Galway (NUIG), Ireland.

Background: In general practice, many infections are treated empirically prior to or without microbiological confirmation. Prediction of antimicrobial susceptibility could optimise prescribing thus improving patient outcomes. Decision tree models are a novel idea to predict AMR at the time of clinical presentation. This study aims to apply a prediction model using a decision tree approach to predict the antimicrobial resistance (AMR) of pathogens causing urinary tract infections (UTI) for patients over 65 years based on pre-existing routine laboratory data.

Methods: Data were extracted from the database of the microbiological laboratory of the University Hospitals Galway (UHG). All urine results from patients over 65 years, their microbiological analysis and susceptibility (AST) results from January 2011 to December 2015 were included. The primary endpoint was culture result and resistance to antimicrobials (nitrofurantoin, trimethoprim, ciprofloxacin, co-amoxiclav, and amoxicillin) commonly used to treat UTI. A non-parametric regression tree analysis i.e. a decision tree model was generated with the 75% of the dataset (training set) and validated with the remaining 25% (test set). The model performance was evaluated measuring Area Under the Curve Receiver Operating Characteristic (AUC_ROC) curve.

Results: A total of 99,101 urine samples of patients over 65 years were submitted for culture over the five years and 27% had significant bacteriuria (≥10 cfu/ml) and AST. The most common identified causative organisms were E.coli, Klebsiella spp. and Proteus spp. E.coli was more often resistant to amoxicillin (66%) followed by Proteus spp. (41%). Klebsiella spp. and Proteus spp. were more often resistant to trimethoprim (78% and 54% respectively). E. coli resistance to nitrofurantoin is low (<10%). The decision tree model showed an AUC-ROC score of 0.68 for culture and in between 0.60 to 0.97 for antimicrobial resistance of the pathogens, with the inclusion of patient's descriptors only. Including the uropathogen in the model did not change model performance.

Conclusions: The decision tree models using patient descriptors available at the time of presentation showed fair to excellent performance in predicting culture and antimicrobial resistance. The presented models provide an alternative approach to decision making on antimicrobial prescribing for UTIs. Increasing more predictors in the model could improve the model performance. Prospective data collection, validation and feasibility testing of the model including data from other laboratories will progress the practical implementation of similar models.
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http://dx.doi.org/10.1016/j.ijmedinf.2019.04.020DOI Listing
July 2019

Antimicrobial resistance patterns of urine culture specimens from 27 nursing homes: Impact of a two-year antimicrobial stewardship intervention.

Infect Control Hosp Epidemiol 2019 07 6;40(7):780-786. Epub 2019 May 6.

Cecil G. Sheps Center for Health Service Research,University of North Carolina,Chapel Hill, North Carolina, United States.

Objective: Identify changes in the prevalence and antimicrobial resistance patterns of potentially pathogenic bacteria in urine cultures during a 2-year antimicrobial stewardship intervention program in nursing homes (NHs).

Design: Before-and-after intervention study.

Setting: The study included 27 NHs in North Carolina.

Methods: We audited all urine cultures ordered before and during an antimicrobial stewardship intervention. Analyses compared culture rates, culture positive rates, and pathogen antimicrobial resistance patterns.

Results: Of 6,718 total urine cultures collected, 68% were positive for potentially pathogenic bacteria. During the intervention, significant reductions in the urine culture and positive culture rates were observed (P = .014). Most of the identified potentially uropathogenic isolates were Escherichia coli (38%), Proteus spp (13%), and Klebsiella pneumoniae (12%). A significant decrease was observed during the intervention period in nitrofurantoin resistance among E. coli (P ≤ .001) and ciprofloxacin resistance among Proteus spp (P ≤ .001); however carbapenem resistance increased for Proteus spp (P ≤ .001). Multidrug resistance also increased for Proteus spp compared to the baseline. The high baseline resistance of E. coli to the commonly prescribed antimicrobials ciprofloxacin and trimethoprim-sulfamethoxazole (TMP/SMX) did not change during the intervention.

Conclusions: The antimicrobial stewardship intervention program significantly reduced urine culture and culture-positive rates. Overall, very high proportions of antimicrobial resistance were observed among common pathogens; however, antimicrobial resistance trended downward but reductions were too small and scattered to conclude that the intervention significantly changed antimicrobial resistance. Longer intervention periods may be needed to effect change in resistance patterns.
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http://dx.doi.org/10.1017/ice.2019.108DOI Listing
July 2019

A comparative analysis of prophylactic antimicrobial use in long-term care facilities in Ireland, 2013 and 2016.

Euro Surveill 2019 03;24(11)

Discipline of Bacteriology, School of Medicine, National University of Ireland Galway (NUIG), Galway, Ireland.

BackgroundLong-term care facilities (LTCFs) are important locations of antimicrobial consumption. Of particular concern is inappropriate prescribing of prophylactic antimicrobials. AimWe aimed to explore factors related to antimicrobial prophylaxis in LTCFs in Ireland. MethodsThe point prevalence surveys of Healthcare-Associated Infections in Long-Term Care Facilities (HALT) were performed in Ireland in May 2013 and 2016. Data were collected on facility (type and stewardship initiatives) and resident characteristics (age, sex, antimicrobial and indication) for those meeting the surveillance definition for a HAI and/or prescribed an antimicrobial. ResultsIn 2013, 9,318 residents (in 190 LTCFs) and in 2016, 10,044 residents (in 224 LTCFs) were included. Of the 10% of residents prescribed antimicrobials, 40% were on prophylaxis, most of which was to prevent urinary tract infection. The main prophylactic agents were: nitrofurantoin (39%) and trimethoprim (41%) for urinary tract (UT); macrolides (47%) for respiratory tract and macrolides and tetracycline (56%) for skin or wounds. More than 50% of the prophylaxis was prescribed in intellectual disability facilities and around 40% in nursing homes. Prophylaxis was recorded more often for females, residents living in LTCFs for more than 1 year and residents with a urinary catheter. No difference in prophylactic prescribing was observed when comparing LTCFs participating and not participating in both years. ConclusionsForty per cent of antimicrobial prescriptions in Irish LTCFs were prophylactic. This practice is not consistent with national antimicrobial prescribing guidelines. Addressing inappropriate prophylaxis prescribing in Irish LTCFs should be a key objective of antimicrobial stewardship initiatives.
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http://dx.doi.org/10.2807/1560-7917.ES.2019.24.11.1800102DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6425550PMC
March 2019

COSUTI: a protocol for the development of a core outcome set (COS) for interventions for the treatment of uncomplicated urinary tract infection (UTI) in adults.

Trials 2019 Feb 7;20(1):106. Epub 2019 Feb 7.

HRB Trials Methodology Research Network, College of Medicine, Nursing & Health Sciences, National University of Ireland, Galway, Ireland.

Background: Urinary tract infections (UTIs) are the second most common infection presenting in the community. Clinical guidelines and decision aids assist health practitioners to treat a UTI; however, treatment practices vary due to patient needs and context of presentation. Numerous trials have evaluated the effectiveness of treatment interventions for UTI; however, it is difficult to compare the results between trials due to inconsistencies between reported outcomes. Poor choice of outcome measures can lead to impairment of evidence synthesis due to the inability to compare outcomes between trials with similar aims. Transparency in selecting and reporting outcomes can be mitigated through the development of an agreed minimum set of outcomes that should be reported in clinical trials, referred to as a core outcome set (COS). This paper presents the protocol for the development of a COS for interventions in the treatment of uncomplicated UTI in adults.

Methods: This COS development consists of three phases. Phase 1 is a systematic review, which aims to identify the core outcomes that have been reported in trials and systematic reviews of interventions treating uncomplicated UTI in adults. Phase 2 consists of a three-round online Delphi survey with stakeholders in the area of treatment interventions for UTI. The aim of this online Delphi survey is to achieve consensus on the importance of the outcomes emerging from Phase 1 of this research. Phase 3 is a consensus meeting to finalise the COS that should be reported in trials evaluating the effectiveness of interventions for the treatment of UTI.

Discussion: It is hoped that the development of a COS for interventions for the treatment of uncomplicated UTI in adults will be adopted as a minimum set of outcomes that should be reported and measured within this context. If the findings from clinical trials related to treatment interventions for UTI are to impact on policy and practice, it is important that the findings from different treatment interventions are comparable across trials.
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http://dx.doi.org/10.1186/s13063-019-3194-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6367821PMC
February 2019

Improving Antimicrobial Prescribing: A Multinomial Model Identifying Factors Associated With First- and Second-Line Prescribing.

J Am Med Dir Assoc 2019 05 13;20(5):624-628. Epub 2018 Dec 13.

Discipline of General Practice, School of Medicine, National University of Ireland Galway, Ireland; Discipline of Bacteriology, School of Medicine, National University of Ireland Galway, Ireland.

Background/objectives: Broad-spectrum, second-line antimicrobials may be prescribed when initial first-line options prove ineffective. This study compares prescribing practices and identifies potential influencing factors for first- and second-line antimicrobials in long-term care facilities.

Design: Point prevalence survey of health care-associated infections and antimicrobial use in long-term care facilities (HALT), expanded by additional data collection.

Setting: Long-term care facilities in Ireland.

Participants: Of long-term care facilities that participated in the HALT study 2016, additional data provided by 77 facilities with a record of 3677 residents.

Measurement: On the survey date, an institutional questionnaire was completed by each participating long-term care facility, and resident questionnaires were completed only for those residents who met a health care-associated infection surveillance definition and/or were prescribed a systemic antimicrobial. All participating long-term care facilities were contacted at a later time point to provide limited anonymized data (age, sex, urinary catheterization, and disorientation) on all current residents. These additional data were matched to the original data set, facilitating multilevel multinominal logistic regression (first-line/second-line/no antimicrobial).

Results: Of 3677 residents in 77 long-term care facilities, 381 (10%) were prescribed systemic antimicrobials on the survey day. Of those, 46% were categorized as second-line choices, with substantial interfacility variation observed with regard to prescription of first- versus second-line antimicrobials. The odds of a second-line antimicrobial prescription for a resident doubled when comparing the highest with the lowest prescribing long-term care facilities (median odds ratio = 2.0, credibility interval = 1.5-2.9). Male residents were less often prescribed first-line antimicrobials [odds ratio (OR) = 0.6, 95% confidence interval (CI) = 0.4-0.9, P = .02]. Long-term care facilities that reported the provision of education on antimicrobial prescribing use significantly less second-line antimicrobials (OR = 0.2, 95% CI = 0.1-0.7, P = .02). Females and residents with a urinary catheter were more likely to receive first-line antimicrobials.

Conclusion/implications: The use of second-line antimicrobials is common practice in long-term care facilities, but education and training on appropriate antimicrobial use has the potential to reduce second-line antimicrobial prescribing, improve patients' outcomes, and reduce antimicrobial resistance.
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http://dx.doi.org/10.1016/j.jamda.2018.10.028DOI Listing
May 2019

Development of an online resource for recruitment research in clinical trials to organise and map current literature.

Clin Trials 2018 12 31;15(6):533-542. Epub 2018 Aug 31.

1 North West Hub for Trials Methodology Research, University of Liverpool, Liverpool, UK.

Background: Recruiting the target number of participants within the pre-specified time frame agreed with funders remains a common challenge in the completion of a successful clinical trial and addressing this is an important methodological priority. While there is growing research around recruitment, navigating this literature to support an evidence-based approach remains difficult. The Online resource for Recruitment Research in Clinical triAls project aims to create an online searchable database of recruitment research to improve access to existing evidence and to identify gaps for future research.

Methods: MEDLINE (Ovid), Scopus, Cochrane Database of Systematic Reviews and Cochrane Methodology Register, Science Citation Index Expanded and Social Sciences Citation Index within the ISI Web of Science and Education Resources Information Center were searched in January 2015. Search strategy results were screened by title and abstract, and full text obtained for potentially eligible articles. Studies reporting or evaluating strategies, interventions or methods used to recruit patients were included along with case reports and studies exploring reasons for patient participation or non-participation. Eligible articles were categorised as systematic reviews, nested randomised controlled trials and other designs evaluating the effects of recruitment strategies (Level 1); studies that report the use of recruitment strategies without an evaluation of impact (Level 2); or articles reporting factors affecting recruitment without presenting a particular recruitment strategy (Level 3). Articles were also assigned to 1, or more, of 42 predefined recruitment domains grouped under 6 categories.

Results: More than 60,000 records were retrieved by the search, resulting in 56,030 unique titles and abstracts for screening, with a further 23 found through hand searches. A total of 4570 full text articles were checked; 2804 were eligible. Six percent of the included articles evaluated the effectiveness of a recruitment strategy (Level 1), with most of these assessing aspects of participant information, either its method of delivery (33%) or its content and format (28%).

Discussion: Recruitment to clinical trials remains a common challenge and an important area for future research. The online resource for Recruitment Research in Clinical triAls project provides a searchable, online database of research relevant to recruitment. The project has identified the need for researchers to evaluate their recruitment strategies to improve the evidence base and broaden the narrow focus of existing research to help meet the complex challenges faced by those recruiting to clinical trials.
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http://dx.doi.org/10.1177/1740774518796156DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6236587PMC
December 2018

Apples to apples: can differences in out-of-hospital cardiac arrest incidence and outcomes between Sweden and Ireland be explained by core Utstein variables?

Scand J Trauma Resusc Emerg Med 2018 May 3;26(1):37. Epub 2018 May 3.

School of Medicine, National University of Ireland Galway, Galway, Ireland.

Background: Variation in reported incidence and outcome based on aggregated data is a persistent feature of out-of-hospital cardiac arrest (OHCA) epidemiology.

Objective: To investigate the extent to which patient-level analysis using core 'Utstein' variables explains inter-country variation between Sweden and the Republic of Ireland.

Methods: A retrospective cross-sectional comparative study was performed, including all Swedish and Irish OHCA cases attended by Emergency Medical Services (EMS-attended OHCA) where resuscitation was attempted from 1st January 2012 to 31st December 2014. Incidence rates per 100,000 population were adjusted for age and gender. Two subgroups were extracted: (1) Utstein - adult patients, bystander-witnessed collapse, presumed medical aetiology, initial shockable rhythm and (2) Emergency Medical Service (EMS)-witnessed events. Multivariable logistic regression analysis was used to identify predictors of survival following multiple imputations of data.

Results: Five thousand eight hundred eighty six Irish and 15,303 Swedish patients were included. Swedish patients were older than Irish patients (median age 71 vs. 66 years respectively). Adjusted incidence was significantly higher in Sweden compared to the Republic of Ireland (52.9 vs. 43.1 per 100,000 population per year). Proportionate survival in Sweden was greater for both subgroups and all age categories. Regression analysis of the Utstein subgroup predicted approximately 17% of variation in outcome, but there was a large unexplained 'country effect' for survival in favour of Sweden (OR 4.40 (95% CI 2.55-7.56)).

Conclusions: Using patient level data, a proportion of inter-country variation was explained, but substantial variation was not explained by the core Utstein variables. Researchers and policy makers should be aware of the potential for unmeasured differences when comparing OHCA incidence and outcomes between countries.
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http://dx.doi.org/10.1186/s13049-018-0505-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5934807PMC
May 2018

Out-of-hospital cardiac arrest survival in international airports.

Resuscitation 2018 Jun 14;127:58-62. Epub 2018 Mar 14.

Discipline of General Practice, National University of Ireland Galway, 1 Distillery Road, Galway, Ireland.

Background: The highest achievable survival rate following out-of-hospital cardiac arrest is unknown. Data from airports serving international destinations (international airports) provide the opportunity to evaluate the success of pre-hospital resuscitation in a relatively controlled but real-life environment.

Methods: This retrospective cohort study included all cases of out-of-hospital cardiac arrest at international airports with resuscitation attempted between January 1st, 2013 and December 31st, 2015. Crude incidence, patient, event characteristics and survival to hospital discharge/survival to 30 days (survival) were calculated. Mixed effect logistic regression analyses were performed to identify predictors of survival. Variability in survival between airports/countries was quantified using the median odds ratio.

Results: There were 800 cases identified, with an average of 40 per airport. Incidence was 0.024/100,000 passengers per year. Percentage survival for all patients was 32%, and 58% for patients with an initial shockable heart rhythm. In adjusted analyses, initial shockable heart rhythm was the strongest predictor of survival (odds ratio, 36.7; 95% confidence interval [CI], 15.5-87.0). In the bystander-witnessed subgroup, delivery of a defibrillation shock by a bystander was a strong predictor of survival (odds ratio 4.8; 95% CI, 3.0-7.8). Grouping of cases was significant at country level and survival varied between countries.

Conclusions: In international airports, 32% of patients survived an out-of-hospital cardiac arrest, substantially more than in the general population. Our analysis suggested similarity between airports within countries, but differences between countries. Systematic data collection and reporting are essential to ensure international airports continually maximise activities to increase survival.
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http://dx.doi.org/10.1016/j.resuscitation.2018.03.024DOI Listing
June 2018

Out-of-hospital cardiac arrest in the home: Can area characteristics identify at-risk communities in the Republic of Ireland?

Int J Health Geogr 2018 02 20;17(1). Epub 2018 Feb 20.

School of Medicine, National University of Ireland Galway, Galway, Ireland.

Background: Internationally, the majority of out-of-hospital cardiac arrests where resuscitation is attempted (OHCAs) occur in private residential locations i.e. at home. The prospect of survival for this patient group is universally dismal. Understanding of the area-level factors that affect the incidence of OHCA at home may help national health planners when implementing community resuscitation training and services.

Methods: We performed spatial smoothing using Bayesian conditional autoregression on case data from the Irish OHCA register. We further corrected for correlated findings using area level variables extracted and constructed for national census data.

Results: We found that increasing deprivation was associated with increased case incidence. The methodology used also enabled us to identify specific areas with higher than expected case incidence.

Conclusions: Our study demonstrates novel use of Bayesian conditional autoregression in quantifying area level risk of a health event with high mortality across an entire country with a diverse settlement pattern. It adds to the evidence that the likelihood of OHCA resuscitation events is associated with greater deprivation and suggests that area deprivation should be considered when planning resuscitation services. Finally, our study demonstrates the utility of Bayesian conditional autoregression as a methodological approach that could be applied in any country using registry data and area level census data.
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http://dx.doi.org/10.1186/s12942-018-0126-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5819205PMC
February 2018

A 2-year comparative study of mold and bacterial counts in air samples from neutral and positive pressure rooms in 2 tertiary care hospitals.

Am J Infect Control 2018 05 4;46(5):590-593. Epub 2018 Jan 4.

Department of Microbiology, Galway University Hospital, Galway, Ireland; School of Medicine, National University of Ireland, Galway, Ireland.

Immunocompromised patients are at risk of invasive fungal infection. These high-risk patients are nursed in protective isolation to reduce the risk of nosocomial aspergillosis while in hospital-ideally in a positive pressure single room with high-efficiency particulate air filtration. However, neutral pressure rooms are a potential alternative, especially for patients requiring both protective and source isolation. This study examined mold and bacterial concentrations in air samples from positive and neutral pressure rooms to assess whether neutral pressure rooms offer a similar environment to that of positive pressure rooms in terms of mold concentrations in the air. Mold concentrations were found to be similar in the positive and neutral pressure room types examined in this study. These results add to the paucity of literature in this area.
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http://dx.doi.org/10.1016/j.ajic.2017.10.019DOI Listing
May 2018

Adverse Effects of Amoxicillin for Acute Lower Respiratory Tract Infection in Primary Care: Secondary and Subgroup Analysis of a Randomised Clinical Trial.

Antibiotics (Basel) 2017 Dec 13;6(4). Epub 2017 Dec 13.

Laboratory Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, 2610 Antwerp, Belgium.

A European placebo-controlled trial of antibiotic treatment for lower respiratory tract infection (LRTI) conducted in 16 primary care practices networks recruited participants between November 2007 and April 2010, and found adverse events (AEs) occurred more often in patients prescribed amoxicillin compared to placebo. This secondary analysis explores the causal relationship and estimates specific AEs (diarrhoea, nausea, rash) due to amoxicillin treatment for LRTI, and if any subgroup is at increased risk of any or a specific AE. A total of 2061 patients were randomly assigned to amoxicillin (1038) and placebo (1023); 595 (28%) were 60 and older. A significantly higher proportion of any AEs (diarrhoea or nausea or rash) (OR = 1.31, 95% CI 1.05-1.64, number needed to harm (NNH) = 24) and of diarrhoea (OR 1.43 95% CI 1.08-1.90, NNH = 29) was reported in the amoxicillin group during the first week after randomisation. Subgroup analysis showed rash was significantly more often reported in males prescribed amoxicillin (interaction term 3.72 95% CI 1.22-11.36; OR of amoxicillin in males 2.79 (95% CI 1.08-7.22). No other subgroup at higher risk was identified. Although the study was not powered for subgroup analysis, this analysis suggests that most patients are likely to be equally harmed when prescribed antibiotics.
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http://dx.doi.org/10.3390/antibiotics6040036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5745479PMC
December 2017

The Effect of Rurality on Out-of-Hospital Cardiac Arrest Resuscitation Incidence: An Exploratory Study of a National Registry Utilizing a Categorical Approach.

J Rural Health 2019 01 26;35(1):78-86. Epub 2017 Aug 26.

Discipline of General Practice, School of Medicine, National University of Ireland Galway, Galway, Ireland.

Purpose: Variation in incidence is a universal feature of out-of-hospital cardiac arrest (OHCA). One potential source of variation is the rurality of the location where the OHCA incident occurs. While previous work has used a simple binary approach to define rurality, the purpose of this study was to use a categorical approach to quantify the impact of urban-rural classification on OHCA incidence in the Republic of Ireland.

Methods: The observed versus expected ratio of OHCA incidence where resuscitation was attempted for the period January 1, 2012, to December 31, 2014, was calculated for each of the 3,408 electoral divisions (ED). EDs were then classified into 1 of 6 urban-rural classes. Multilevel modeling was used to test for variation in incidence ratios (IR) across the urban-rural classes.

Findings: A total of 4,755 cases of adult OHCA, not witnessed by Emergency Medical Services, where resuscitation was attempted were included in the study. The number of EDs in each category was as follows: city (n = 477); town (n = 293); near village (n = 182); remote village (n = 84); near rural (n = 1,479); remote rural (n = 893). The IR per ED varied from 0 to 18.38 (EDs, n = 3,408). Multilevel modeling showed that 2.36% of variation in IR was due to urban-rural classification. This dropped to 0.45% when adjusted for ED deprivation score and median distance to an ambulance station. The addition of other explanatory variables did not improve the model.

Conclusion: OHCA variation in Ireland is limited and almost fully explained by area-level deprivation and proximity to ambulance stations.
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http://dx.doi.org/10.1111/jrh.12266DOI Listing
January 2019

Epidemiology of gestational diabetes mellitus according to IADPSG/WHO 2013 criteria among obese pregnant women in Europe.

Diabetologia 2017 10 12;60(10):1913-1921. Epub 2017 Jul 12.

Galway Diabetes Research Centre, College of Medicine, Nursing and Health Sciences, National University of Ireland, University Road, Galway, H91 TK33, Ireland.

Aims/hypothesis: Accurate prevalence estimates for gestational diabetes mellitus (GDM) among pregnant women in Europe are lacking owing to the use of a multitude of diagnostic criteria and screening strategies in both high-risk women and the general pregnant population. Our aims were to report important risk factors for GDM development and calculate the prevalence of GDM in a cohort of women with BMI ≥29 kg/m across 11 centres in Europe using the International Association of the Diabetes and Pregnancy Study Groups (IADPSG)/WHO 2013 diagnostic criteria.

Methods: Pregnant women (n = 1023, 86.3% European ethnicity) with a BMI ≥29.0 kg/m enrolled into the Vitamin D and Lifestyle Intervention for GDM Prevention (DALI) pilot, lifestyle and vitamin D studies of this pan-European multicentre trial, attended for an OGTT during pregnancy. Demographic, anthropometric and metabolic data were collected at enrolment and throughout pregnancy. GDM was diagnosed using IADPSG/WHO 2013 criteria. GDM treatment followed local policies.

Results: The number of women recruited per country ranged from 80 to 217, and the dropout rate was 7.1%. Overall, 39% of women developed GDM during pregnancy, with no significant differences in prevalence across countries. The prevalence of GDM was high (24%; 242/1023) in early pregnancy. Despite interventions used in the DALI study, a further 14% (94/672) had developed GDM when tested at mid gestation (24-28 weeks) and 13% (59/476) of the remaining cohort at late gestation (35-37 weeks). Demographics and lifestyle factors were similar at baseline between women with GDM and those who maintained normal glucose tolerance. Previous GDM (16.5% vs 7.9%, p = 0.002), congenital malformations (6.4% vs 3.3%, p = 0.045) and a baby with macrosomia (31.4% vs 17.9%, p = 0.001) were reported more frequently in those who developed GDM. Significant anthropometric and metabolic differences were already present in early pregnancy between women who developed GDM and those who did not.

Conclusions/interpretation: The prevalence of GDM diagnosed by the IADPSG/WHO 2013 GDM criteria in European pregnant women with a BMI ≥29.0 kg/m is substantial, and poses a significant health burden to these pregnancies and to the future health of the mother and her offspring. Uniform criteria for GDM diagnosis, supported by robust evidence for the benefits of treatment, are urgently needed to guide modern GDM screening and treatment strategies.
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http://dx.doi.org/10.1007/s00125-017-4353-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6448875PMC
October 2017

A longitudinal and multicentre study of burnout and error in Irish junior doctors.

Postgrad Med J 2017 Nov 9;93(1105):660-664. Epub 2017 Jun 9.

School of Medicine, National University of Ireland Galway, Galway, Ireland.

Background: Junior doctors have been found to suffer from high levels of burnout.

Aims: To measure burnout in a population of junior doctors in Ireland and identify if: levels of burnout are similar to US medical residents; there is a change in the pattern of burnout during the first year of postgraduate clinical practice; and burnout is associated with self-reported error.

Methods: The Maslach Burnout Inventory-Human Services Survey was distributed to Irish junior doctors from five training networks in the last quarter of 2015 when they were approximately 4 months into their first year of clinical practice (time 1), and again 6 months later (time 2). The survey assessed burnout and whether they had made a medical error that had 'played on (their) mind'.

Results: A total of 172 respondents out of 601 (28.6%) completed the questionnaire on both occasions. Irish junior doctors at time 2 were more burned out than a sample of US medical residents (72.6% and 60.3% burned out, respectively; p=0.001). There was a significant increase in emotional exhaustion from time 1 to time 2 (p=0.007). The association between burnout and error was significant at time 2 only (p=0.03). At time 2, of those respondents who were burned out, 81/122 (66.4%) reported making an error. A total of 22/46 (47.8%) of the junior doctors who were not burned out at time 2 reported an error.

Conclusion: Current levels of burnout are unsustainable and place the health of both junior doctors and their patients at risk.
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http://dx.doi.org/10.1136/postgradmedj-2016-134626DOI Listing
November 2017

Using Mobile Phones to Collect Patient Data: Lessons Learned From the SIMPle Study.

JMIR Res Protoc 2017 Apr 25;6(4):e61. Epub 2017 Apr 25.

Discipline of General Practice, National University of Ireland Galway, Galway, Ireland.

Background: Mobile phones offer new opportunities to efficiently and interactively collect real-time data from patients with acute illnesses, such as urinary tract infections (UTIs). One of the main benefits of using mobile data collection methods is automated data upload, which can reduce the chance of data loss, an issue when using other data collection methods such as paper-based surveys.

Objective: The aim was to explore differences in collecting data from patients with UTI using text messaging, a mobile phone app (UTI diary), and an online survey. This paper provides lessons learned from integrating mobile data collection into a randomized controlled trial.

Methods: Participants included UTI patients consulting in general practices that were participating in the Supporting the Improvement and Management of UTI (SIMPle) study. SIMPle was designed to improve prescribing antimicrobial therapies for UTI in the community. Patients were invited to reply to questions regarding their UTI either via a prospective text message survey, a mobile phone app (UTI diary), or a retrospective online survey. Data were collected from 329 patients who opted in to the text message survey, 71 UTI patients through the mobile phone UTI symptom diary app, and 91 online survey participants.

Results: The age profile of UTI diary app users was younger than that of the text message and online survey users. The largest dropout for both the text message survey respondents and UTI diary app users was after the initial opt-in message; once the participants completed question 1 of the text message survey or day 2 in the UTI diary app, they were more likely to respond to the remaining questions/days.

Conclusions: This feasibility study highlights the potential of using mobile data collection methods to capture patient data. As well as improving the efficiency of data collection, these novel approaches highlight the advantage of collecting data in real time across multiple time points. There was little variation in the number of patients responding between text message survey, UTI diary, and online survey, but more patients participated in the text message survey than the UTI diary app. The choice between designing a text message survey or UTI diary app will depend on the age profile of patients and the type of information the researchers' desire.

Trial Registration: ClinicalTrials.gov NCT01913860; https://clinicaltrials.gov/ct2/show/NCT01913860 (Archived by WebCite at http://www.webcitation.org/6pfgCztgT).
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http://dx.doi.org/10.2196/resprot.6389DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5424123PMC
April 2017

The cost effectiveness of the SIMPle intervention to improve antimicrobial prescribing for urinary tract infection in primary care.

J Public Health (Oxf) 2017 12;39(4):e282-e289

Discipline of Bacteriology, School of Medicine, National University of Ireland, Galway, Ireland.

Background: Antimicrobial resistance is a major public health issue. This study examines the cost effectiveness of the SIMPle (Supporting the Improvement and Management of Prescribing for Urinary Tract Infections (UTI)) intervention to improve antimicrobial prescribing in primary care in Ireland.

Methods: An economic evaluation was conducted alongside a cluster randomized controlled trial of 30 general practices and 2560 patients with a diagnosis of UTI. Practices were randomized to the usual practice control or the SIMPle intervention (arm A or B). Data at 6 months follow-up were used to estimate incremental costs, incremental effectiveness in terms of first-line antimicrobial prescribing for UTI and cost effectiveness acceptability curves.

Results: The SIMPle intervention was, on average, more costly and more effective than the control. The probability of intervention arm A being cost effective was 0.280, 0.995 and 1.000 at threshold values of €50, €150 and €250 per percentage point increase in first-line antimicrobial prescribing respectively. The equivalent probabilities for intervention arm B were 0.121, 0.863 and 0.985, respectively.

Conclusions: The cost effectiveness of the SIMPle intervention depends on the value placed on improving antimicrobial prescribing. Future studies should examine the wider and longer term costs and outcomes of improving antimicrobial prescribing.
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http://dx.doi.org/10.1093/pubmed/fdw102DOI Listing
December 2017

Reconsultation and Antimicrobial Treatment of Urinary Tract Infection in Male and Female Patients in General Practice.

Antibiotics (Basel) 2016 Sep 15;5(3). Epub 2016 Sep 15.

Discipline of General Practice, School of Medicine, National University of Ireland Galway (NUIG), Galway, Ireland.

Current antimicrobial prescribing guidelines indicate that male and female patients with urinary tract infections (UTIs) should be treated with same antimicrobials but for different durations. The aim of this study was to explore the differences in reconsultations and antimicrobial prescribing for UTI for both males and females. A total of 2557 adult suspected UTI patients participating in the Supporting the Improvement and Management of Prescribing for urinary tract infection (SIMPle) study from 30 general practices were analyzed. An antimicrobial was prescribed significantly more often to females (77%) than males (63%). Nitrofurantoin was prescribed more often for females and less often for males (58% vs. 41%), while fluoroquinolones were more often prescribed for males (11% vs. 3%). Overall, reconsultation was 1.4 times higher in females, and if the antimicrobial prescribed was not the recommended first-line (nitrofurantoin), reconsultation after empirical prescribing was significantly higher. However, the reconsultation was similar for males and females if the antimicrobial prescribed was first-line. When a urine culture was obtained, a positive culture was the most important predictor of reconsultation (Odds ratio 1.8 (95% CI 1.3-2.5)). This suggests, when prescribing empirically, that male and female UTI patients should initially be treated with first-line antimicrobials (nitrofurantoin) with different durations (50-100 mg four times daily for three days in females and seven days for males). However, the consideration of a culture test before prescribing antimicrobials may improve outcomes.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5039527PMC
http://dx.doi.org/10.3390/antibiotics5030031DOI Listing
September 2016

Exploring Experiences of Delayed Prescribing and Symptomatic Treatment for Urinary Tract Infections among General Practitioners and Patients in Ambulatory Care: A Qualitative Study.

Antibiotics (Basel) 2016 Aug 15;5(3). Epub 2016 Aug 15.

Discipline of General Practice, School of Medicine, National University of Ireland Galway, Galway, Ireland.

"Delayed or back up" antibiotic prescriptions and "symptomatic" treatment may help to reduce inappropriate antibiotic prescribing for Urinary Tract Infections (UTI) in the future. However, more research needs to be conducted in this area before these strategies can be readily promoted in practice. This study explores General Practitioner (GP) and patient attitudes and experiences regarding the use of delayed or back-up antibiotic and symptomatic treatment for UTI. Qualitative face to face interviews with General Practitioners (n = 7) from one urban and one rural practice and telephone interviews with UTI patients (n = 14) from a rural practice were undertaken. Interviews were analysed using framework analysis. GPs believe that antibiotics are necessary when treating UTI. There was little consensus amongst GPs regarding the role of delayed prescribing or symptomatic treatment for UTI. Delayed prescribing may be considered for patients with low grade symptoms and a negative dipstick test. Patients had limited experience of delayed prescribing for UTI. Half indicated they would be satisfied with a delayed prescription the other half would question it. A fear of missing a serious illness was a significant barrier to symptomatic treatment for both GP and patient. The findings of this research provide insight into antibiotic prescribing practices in general practice. It also highlights the need for further empirical research into the effectiveness of alternative treatment strategies such as symptomatic treatment of UTI before such strategies can be readily adopted in practice.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5039523PMC
http://dx.doi.org/10.3390/antibiotics5030027DOI Listing
August 2016

Out-of-hospital cardiac arrest attended by ambulance services in Ireland: first 2 years' results from a nationwide registry.

Emerg Med J 2016 Nov 2;33(11):776-781. Epub 2016 Aug 2.

School of Medicine, National University of Ireland Galway, Galway, Ireland.

Background: National data collection provides information on out-of-hospital cardiac arrest (OHCA) incidence, management and outcomes that may not be generalisable from smaller studies. This retrospective cohort study describes the first 2 years' results from the Irish National Out-of-Hospital Cardiac Arrest Register (OHCAR).

Methods: Data on OHCAs attended by emergency medical services (EMS) where resuscitation was attempted (EMS-treated) were collected from ambulance services and entered onto OHCAR. Descriptive analysis of the study population was performed, and regression analysis was performed on the subgroup of adult patients with a bystander-witnessed event of presumed cardiac aetiology and an initial shockable rhythm (Utstein group).

Results: 3701 EMS-treated OHCAs were recorded for the study period (1 January 2012-31 December 2013). Incidence was 39/100 000 population/year. In the Utstein group (n=577), compared with the overall group, there was a higher proportion of male patients, public event location, bystander cardiopulmonary resuscitation (CPR) and early defibrillation. Median EMS call-response interval was similar in both groups. A higher proportion of patients in the Utstein group achieved return of spontaneous circulation (35% vs 17%) and survival to hospital discharge (22% vs 6%). After multivariate adjustment for the Utstein group, the following variables were found to be independent predictors of the outcome survival to hospital discharge: public event location (OR 3.1 (95% CI 1.9 to 5.0)); bystander CPR (2.4 (95% CI 1.2 to 4.9)); EMS response of 8 min or less (2.2 (95% CI 1.3 to 3.6)).

Conclusions: This study highlights the role of nationwide registries in quantifying, monitoring and benchmarking OHCA incidence and outcome, providing baseline data upon which service improvement effects can be measured.
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http://dx.doi.org/10.1136/emermed-2015-205107DOI Listing
November 2016

Using qualitative insights to change practice: exploring the culture of antibiotic prescribing and consumption for urinary tract infections.

BMJ Open 2016 Jan 11;6(1):e008894. Epub 2016 Jan 11.

Discipline of General Practice, School of Medicine, National University of Ireland Galway, Galway, Ireland Discipline of Bacteriology, School of Medicine, National University of Ireland Galway, Galway, Ireland.

Objectives: The aim of this paper is to explore the culture of antibiotic prescribing and consumption in the community for urinary tract infections (UTI) from the perspective of the general practitioners (GPs) and community member.

Design: Indepth interviews were conducted with GPs, and focus groups were held with community members.

Setting: General practice and community setting.

Participants: 15 GPs practising in rural and urban locations in Ireland participated in the indepth interviews. 6 focus groups (n=42) with participants who had direct or indirect experiences with UTI were also undertaken.

Results: The decision to prescribe or consume an antibiotic for a UTI is a set of complex processes including need recognition, information search and evaluation processes governed by the relationship and interactions between the GP and the patient. Different GP and patient decision-making profiles emerged emphasising the diversity and variety of general practice in real-life settings. The GP findings showed a requirement for more microbiological information on antibiotic resistance patterns to inform prescribing decisions. Focus group participants wanted a conversation with the GP about their illness and the treatment options available.

Conclusions: Collectively, this research identified the consultation as a priority intervention environment for stimulating change in relation to antibiotics. This paper demonstrates how qualitative research can identify the interacting processes which are instrumental to the decision to prescribe or consume an antibiotic for a suspected UTI. Qualitative research empowers researchers to investigate the what, how and why of interventions in real-life setting. Qualitative research can play a critical and instrumental role in designing behavioural change strategies with high impact on practice. The results of this research were used to design a complex intervention informed by social marketing.

Trial Registration Number: NCT01913860; Pre-results.
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http://dx.doi.org/10.1136/bmjopen-2015-008894DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4716200PMC
January 2016