Papers by Philip Howard
European Journal of Hospital Pharmacy
Patients with poor adherence had a higher risk of virological failure (OR = 11.67; CI95 = 1.14-11... more Patients with poor adherence had a higher risk of virological failure (OR = 11.67; CI95 = 1.14-119.54;p = 0.039) Conclusions Adherence to HAART represents a significant challenge in the paediatric HIV population. The P/d was significantly associated with adherence. Every pill/ day increased up to 2.3-fold the risk of non-adherence to HAART. Simplifying HAART by reducing the pill burden may contribute to improving compliance in the paediatric HIV population.
Background: A variety of indicators is commonly used to monitor antibiotic prescriptions as part ... more Background: A variety of indicators is commonly used to monitor antibiotic prescriptions as part of national anti-microbial stewardship (AMS) programmes. Objectives: To make an inventory of indicators that assess antibiotic prescriptions and are linked to specific targets and incentives, at a national level. Methods: A cross-sectional survey (three-item questionnaire) was conducted in 2017 among all ESGAP (ESCMID Study Group for Antimicrobial stewardshiP) members, coming from 23 European countries and 16 non-European countries. Results: Almost all (20/23, 87%) European countries belonging to the ESGAP network participated, as well as one non-European country. Computerized systems routinely linking antibiotic prescriptions to clinical diagnoses were reported for only two countries (Turkey and Croatia). Only 6/21 (29%) countries had national indicators with both clear targets and incentives (Bulgaria, Croatia, France, the Netherlands, Norway and Portugal). We identified a total of 21 different indicators used in these countries, 16 concerning inpatients (9 quality indicators and 7 quantity metrics) and 8 concerning outpatients (all quantity metrics); some indicators were used in both settings. Three types of incentives were used: financing mechanism, hospitals' accreditation and public reporting. Some respondents reported that such indicators with both clear targets and incentives were used at a regional level in their country (e.g. Andalusia in Spain and England in the UK). Conclusions: National indicators, with clear targets and incentives, are not commonly used in Europe and we observed wide variations between countries regarding the selected indicators, the units of measure and the chosen targets.
Purpose. We sought to explore the current status of antifungal stewardship (AFS) initiatives acro... more Purpose. We sought to explore the current status of antifungal stewardship (AFS) initiatives across National Health Service (NHS) Trusts within England, the challenges and barriers as well as ways to improve current AFS programmes. Methodology. An electronic survey was sent to all 155 acute NHS acute Trusts in England. A total of 47 Trusts, corresponding to 30 % of English acute Trusts, returned a survey; 46 Trusts (98 %) had an antimicrobial stewardship (AMS) programme but only 5 (11 %) had a dedicated AFS programme. Overall, 20 (43 %) Trusts said they included AFS as part of their AMS programmes. From those conducting AFS programmes, 7 (28 %) have an AFS/management team, 16 (64 %) monitor and report on antifungal usage, 5 (20 %) have dedicated AFS ward rounds and 12 (48 %) are directly involved in the management of invasive fungal infections. Results/Key findings. Altogether, 13 acute Trusts (52 %) started their AFS programme to manage costs, whilst 12 (48 %) commenced the programme due to clinical need; 27 (73 %) declared that they would increase their AFS initiatives if they could. Of those without an AFS programme, 14 (67 %) responded that this was due to lack of resources/staff time. Overall, 12 Trusts (57 %) responded that the availability of rapid diagnostics and clinical support would enable them to conduct AFS activities. Conclusion. Although a minority of Trusts conduct dedicated AFS programmes, nearly half include AFS as part of routine AMS activities. Cost issues are the main driver for AFS, followed by clinical need. The availability of rapid diagnostics and clinical support could help increase AFS initiatives.
Purpose. We sought to explore the current status of antifungal stewardship (AFS) initiatives acro... more Purpose. We sought to explore the current status of antifungal stewardship (AFS) initiatives across National Health Service (NHS) Trusts within England, the challenges and barriers, as well as ways to improve current AFS programmes. Methodology. An electronic survey was sent to all 155 acute NHS Trusts in England. A total of 47 Trusts, corresponding to 30 % of English acute Trusts, responded to the the survey; 46 Trusts (98 %) had an antimicrobial stewardship (AMS) programme but only 5 (11 %) had a dedicated AFS programme. Overall, 20 (43 %) Trusts said they included AFS as part of their AMS programmes. From those conducting AFS programmes, 7 (28 %) have an AFS/management team, 16 (64 %) monitor and report on antifungal usage, 5 (20 %) have dedicated AFS ward rounds and 12 (48 %) are directly involved in the management of invasive fungal infections. Results/Key findings. Altogether, 13 acute Trusts (52 %) started their AFS programme to manage costs, whilst 12 (48 %) commenced the programme due to clinical need; 27 (73 %) declared that they would increase their AFS initiatives if they could. Of those without an AFS programme, 14 (67 %) responded that this was due to lack of resources/staff time. Overall, 12 Trusts (57 %) responded that the availability of rapid diagnostics and clinical support would enable them to conduct AFS activities. Conclusion. Although a minority of Trusts conduct dedicated AFS programmes, nearly half include AFS as part of routine AMS activities. Cost issues are the main driver for AFS, followed by clinical need. The availability of rapid diagnostics and clinical support could help increase AFS initiatives.
Journal of Antimicrobial Chemotherapy , Nov 2013
Objectives To learn about medical students' knowledge of and perspectives on antibiotic prescribi... more Objectives To learn about medical students' knowledge of and perspectives on antibiotic prescribing and resistance, with the aim of helping to develop educational programmes.
Methods Final-year students at seven European medical schools were invited to participate in an online survey in 2012.
Results The response rate was 35% (338/961). Most students (74%) wanted more education on choosing antibiotic treatments. Students at all schools felt most confident in diagnosing an infection and least confident in choosing combination therapies, choosing the correct dose and interval of administration and not prescribing in cases of diagnostic uncertainty. Students felt that too many prescriptions and too much broad-spectrum antibiotic use were the most important contributors to resistance; some (24%) believed poor hand hygiene was not at all important. Most students (92%) believed that resistance is a national problem. Most (66%) felt that the antibiotics they would prescribe would contribute to resistance, and almost all (98%) felt that resistance would be a greater problem in the future. Most students (83%) incorrectly thought that rates of methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia had significantly increased over the past decade in their countries. There was little appreciation of the relative burden of resistance in Europe compared with road traffic accidents (around two to three times greater mortality) and lung cancer (around 10 times greater mortality).
Conclusions Students wanted further education on antibiotic prescribing, and areas of lack of confidence were found. Students overestimated the current burden of resistant bacteria and were unaware of successes in reducing MRSA infections. Educational and stewardship programmes may benefit from including more cases of diagnostic uncertainty, and highlighting successes such as MRSA prevention, as evidence for the importance of current interventions.
Journal of Cardiac Surgery, May 2013
Abstract
Objectives
To determine if changing from multidose cefuroxime-based to flucloxacillin ... more Abstract
Objectives
To determine if changing from multidose cefuroxime-based to flucloxacillin (or teicoplanin) and gentamicin-based antibiotic prophylaxis for cardiac surgery was as effective at preventing infections without increasing postoperative renal impairment.
Methods
Outcomes in consecutive patients from two 18-month periods with the different antibiotic regimes. Group 1 (1725 patients)—cefuroxime 1.5 g at induction and postoperatively. Group 2 (1695 patients)—flucloxacillin (or teicoplanin) and gentamicin at induction, valve procedures received further dose on weaning bypass. Primary end-points: new/worsening renal impairment, surgical site infection (SSI), Clostridium difficile infection (CDI). Multivariate logistic regression and interrupted time series segmented regression analysis were used.
Results
Demographics were similar (age, EuroSCORE, gender, preoperative renal impairment). There were fewer wound infections in group 2: SSI 3.2% (group 1) versus 2.7% (group2) (p = NS); sternal infections 2.7% versus 2.0% (p = NS). New or worsening renal impairment was less frequent with gentamicin (4.3% group 1 vs. 3.4% group 2, p = NS). Mean postoperative stay 9.4 days (group 1) versus 8.7 days (group 2) (p = 0.05). Logistic regression identified: diabetes, EuroSCORE associated with increased risk of renal and infective complications; female gender, pre-existing renal impairment associated with increased risk of acute renal impairment; bypass time associated with increased risk of wound infection. There were nine CDIs in group 1 compared with one in group 2 (p = 0.02).
Conclusions
The change from multidose cephalosporin prophylaxis to short-course flucloxacillin (or teicoplanin) and gentamicin was not associated with an increase in renal complications, and resulted in significantly fewer CDIs, with no significant change in the incidence of wound infections. doi: 10.1111/jocs.12155 (J Card Surg 2013;28:512–516)
Objectives: To assess the impact of an infection team review of patients receiving antibiotics in... more Objectives: To assess the impact of an infection team review of patients receiving antibiotics in six hospitals across the UK and to establish the suitability of these patients for continued care in the community.
Methods: An evaluation audit tool was used to assess all patients on antibiotic treatment on acute wards on a given day. Clinical and antibiotic use data were collected by an infection team (doctor, nurse and antibiotic
pharmacist). Assessments were made of the requirement for continuing antibiotic treatment, route and duration [including intravenous (iv)/oral switch] and of the suitability of the patients for discharge from hospital and their requirement for community support.
Results: Of 1356 patients reviewed, 429 (32%) were on systemic antibiotics, comprising 165 (38%) on iv+oral antibiotics and 264 (62%) on oral antibiotics alone. Ninety-nine (23%) patients (including 26 on iv antibiotics) had their antibiotics stopped immediately on clinical grounds. The other 330 (77%) patients (including 139 on iv antibiotics) needed to continue antibiotics, although 47 (34%) could be switched to oral. Eighty-nine (21%) patients were considered eligible for discharge, comprising 10 who would have required outpatient parenteral antibiotic therapy (OPAT), 55 who were suitable for oral outpatient treatment and 24 who had their antibiotics stopped.
Conclusions: Infection team review had a significant impact on antimicrobial use, facilitating iv to oral switch and a reduction in the volume of antibiotic use, possibly reducing the risk of healthcare-associated complications
and infections. It identified many patients who could potentially have been managed in the community with appropriate resources, saving 481 bed-days. The health economics are reported in a companion paper.
Keywords: antibiotic treatment, hospital length of stay, OPAT, patient pathway
The Journal of antimicrobial chemotherapy, Jan 1, 2010
Objectives: To describe the methodology in developing an antimicrobial self-assessment toolkit (A... more Objectives: To describe the methodology in developing an antimicrobial self-assessment toolkit (ASAT).
Conference Presentations by Philip Howard
([email protected]), C. Richman Background Background: As part of the UK 5 year antimicrobia... more ([email protected]), C. Richman Background Background: As part of the UK 5 year antimicrobial resistance strategy, an incentive scheme for hospitals was introduced for the financial year 2016-7. It required a reduction of 1% per admission for three antibacterial indicators compared to the baseline financial year of 2013-4: total antibacterials supplied to in-patients, at discharge and to outpatients (ATC J01), carbapenems (J01DH) and piperacillin-tazobactam (J01CR05) In addition, hospitals are required to submit quarterly antibacterial consumption data, and collect data on whether a documented review of empiric antibiotic prescribing has occurred. The drivers for the CQUIN (Commissioning for Quality and Innovation) were a 6% increase in hospital total antibacterial prescribing per admission over a 4 year period 2011-4, a 36% increase in carbapenem prescribing (DDD/admission) and a 56% increase in piperacillin-tazobactam (DDD/admission) plus a 31% increase in Escherichia coli resistance and 36% increase in Klebsiella pneumonia resistance.
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Papers by Philip Howard
Methods Final-year students at seven European medical schools were invited to participate in an online survey in 2012.
Results The response rate was 35% (338/961). Most students (74%) wanted more education on choosing antibiotic treatments. Students at all schools felt most confident in diagnosing an infection and least confident in choosing combination therapies, choosing the correct dose and interval of administration and not prescribing in cases of diagnostic uncertainty. Students felt that too many prescriptions and too much broad-spectrum antibiotic use were the most important contributors to resistance; some (24%) believed poor hand hygiene was not at all important. Most students (92%) believed that resistance is a national problem. Most (66%) felt that the antibiotics they would prescribe would contribute to resistance, and almost all (98%) felt that resistance would be a greater problem in the future. Most students (83%) incorrectly thought that rates of methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia had significantly increased over the past decade in their countries. There was little appreciation of the relative burden of resistance in Europe compared with road traffic accidents (around two to three times greater mortality) and lung cancer (around 10 times greater mortality).
Conclusions Students wanted further education on antibiotic prescribing, and areas of lack of confidence were found. Students overestimated the current burden of resistant bacteria and were unaware of successes in reducing MRSA infections. Educational and stewardship programmes may benefit from including more cases of diagnostic uncertainty, and highlighting successes such as MRSA prevention, as evidence for the importance of current interventions.
Objectives
To determine if changing from multidose cefuroxime-based to flucloxacillin (or teicoplanin) and gentamicin-based antibiotic prophylaxis for cardiac surgery was as effective at preventing infections without increasing postoperative renal impairment.
Methods
Outcomes in consecutive patients from two 18-month periods with the different antibiotic regimes. Group 1 (1725 patients)—cefuroxime 1.5 g at induction and postoperatively. Group 2 (1695 patients)—flucloxacillin (or teicoplanin) and gentamicin at induction, valve procedures received further dose on weaning bypass. Primary end-points: new/worsening renal impairment, surgical site infection (SSI), Clostridium difficile infection (CDI). Multivariate logistic regression and interrupted time series segmented regression analysis were used.
Results
Demographics were similar (age, EuroSCORE, gender, preoperative renal impairment). There were fewer wound infections in group 2: SSI 3.2% (group 1) versus 2.7% (group2) (p = NS); sternal infections 2.7% versus 2.0% (p = NS). New or worsening renal impairment was less frequent with gentamicin (4.3% group 1 vs. 3.4% group 2, p = NS). Mean postoperative stay 9.4 days (group 1) versus 8.7 days (group 2) (p = 0.05). Logistic regression identified: diabetes, EuroSCORE associated with increased risk of renal and infective complications; female gender, pre-existing renal impairment associated with increased risk of acute renal impairment; bypass time associated with increased risk of wound infection. There were nine CDIs in group 1 compared with one in group 2 (p = 0.02).
Conclusions
The change from multidose cephalosporin prophylaxis to short-course flucloxacillin (or teicoplanin) and gentamicin was not associated with an increase in renal complications, and resulted in significantly fewer CDIs, with no significant change in the incidence of wound infections. doi: 10.1111/jocs.12155 (J Card Surg 2013;28:512–516)
Methods: An evaluation audit tool was used to assess all patients on antibiotic treatment on acute wards on a given day. Clinical and antibiotic use data were collected by an infection team (doctor, nurse and antibiotic
pharmacist). Assessments were made of the requirement for continuing antibiotic treatment, route and duration [including intravenous (iv)/oral switch] and of the suitability of the patients for discharge from hospital and their requirement for community support.
Results: Of 1356 patients reviewed, 429 (32%) were on systemic antibiotics, comprising 165 (38%) on iv+oral antibiotics and 264 (62%) on oral antibiotics alone. Ninety-nine (23%) patients (including 26 on iv antibiotics) had their antibiotics stopped immediately on clinical grounds. The other 330 (77%) patients (including 139 on iv antibiotics) needed to continue antibiotics, although 47 (34%) could be switched to oral. Eighty-nine (21%) patients were considered eligible for discharge, comprising 10 who would have required outpatient parenteral antibiotic therapy (OPAT), 55 who were suitable for oral outpatient treatment and 24 who had their antibiotics stopped.
Conclusions: Infection team review had a significant impact on antimicrobial use, facilitating iv to oral switch and a reduction in the volume of antibiotic use, possibly reducing the risk of healthcare-associated complications
and infections. It identified many patients who could potentially have been managed in the community with appropriate resources, saving 481 bed-days. The health economics are reported in a companion paper.
Keywords: antibiotic treatment, hospital length of stay, OPAT, patient pathway
Conference Presentations by Philip Howard
Methods Final-year students at seven European medical schools were invited to participate in an online survey in 2012.
Results The response rate was 35% (338/961). Most students (74%) wanted more education on choosing antibiotic treatments. Students at all schools felt most confident in diagnosing an infection and least confident in choosing combination therapies, choosing the correct dose and interval of administration and not prescribing in cases of diagnostic uncertainty. Students felt that too many prescriptions and too much broad-spectrum antibiotic use were the most important contributors to resistance; some (24%) believed poor hand hygiene was not at all important. Most students (92%) believed that resistance is a national problem. Most (66%) felt that the antibiotics they would prescribe would contribute to resistance, and almost all (98%) felt that resistance would be a greater problem in the future. Most students (83%) incorrectly thought that rates of methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia had significantly increased over the past decade in their countries. There was little appreciation of the relative burden of resistance in Europe compared with road traffic accidents (around two to three times greater mortality) and lung cancer (around 10 times greater mortality).
Conclusions Students wanted further education on antibiotic prescribing, and areas of lack of confidence were found. Students overestimated the current burden of resistant bacteria and were unaware of successes in reducing MRSA infections. Educational and stewardship programmes may benefit from including more cases of diagnostic uncertainty, and highlighting successes such as MRSA prevention, as evidence for the importance of current interventions.
Objectives
To determine if changing from multidose cefuroxime-based to flucloxacillin (or teicoplanin) and gentamicin-based antibiotic prophylaxis for cardiac surgery was as effective at preventing infections without increasing postoperative renal impairment.
Methods
Outcomes in consecutive patients from two 18-month periods with the different antibiotic regimes. Group 1 (1725 patients)—cefuroxime 1.5 g at induction and postoperatively. Group 2 (1695 patients)—flucloxacillin (or teicoplanin) and gentamicin at induction, valve procedures received further dose on weaning bypass. Primary end-points: new/worsening renal impairment, surgical site infection (SSI), Clostridium difficile infection (CDI). Multivariate logistic regression and interrupted time series segmented regression analysis were used.
Results
Demographics were similar (age, EuroSCORE, gender, preoperative renal impairment). There were fewer wound infections in group 2: SSI 3.2% (group 1) versus 2.7% (group2) (p = NS); sternal infections 2.7% versus 2.0% (p = NS). New or worsening renal impairment was less frequent with gentamicin (4.3% group 1 vs. 3.4% group 2, p = NS). Mean postoperative stay 9.4 days (group 1) versus 8.7 days (group 2) (p = 0.05). Logistic regression identified: diabetes, EuroSCORE associated with increased risk of renal and infective complications; female gender, pre-existing renal impairment associated with increased risk of acute renal impairment; bypass time associated with increased risk of wound infection. There were nine CDIs in group 1 compared with one in group 2 (p = 0.02).
Conclusions
The change from multidose cephalosporin prophylaxis to short-course flucloxacillin (or teicoplanin) and gentamicin was not associated with an increase in renal complications, and resulted in significantly fewer CDIs, with no significant change in the incidence of wound infections. doi: 10.1111/jocs.12155 (J Card Surg 2013;28:512–516)
Methods: An evaluation audit tool was used to assess all patients on antibiotic treatment on acute wards on a given day. Clinical and antibiotic use data were collected by an infection team (doctor, nurse and antibiotic
pharmacist). Assessments were made of the requirement for continuing antibiotic treatment, route and duration [including intravenous (iv)/oral switch] and of the suitability of the patients for discharge from hospital and their requirement for community support.
Results: Of 1356 patients reviewed, 429 (32%) were on systemic antibiotics, comprising 165 (38%) on iv+oral antibiotics and 264 (62%) on oral antibiotics alone. Ninety-nine (23%) patients (including 26 on iv antibiotics) had their antibiotics stopped immediately on clinical grounds. The other 330 (77%) patients (including 139 on iv antibiotics) needed to continue antibiotics, although 47 (34%) could be switched to oral. Eighty-nine (21%) patients were considered eligible for discharge, comprising 10 who would have required outpatient parenteral antibiotic therapy (OPAT), 55 who were suitable for oral outpatient treatment and 24 who had their antibiotics stopped.
Conclusions: Infection team review had a significant impact on antimicrobial use, facilitating iv to oral switch and a reduction in the volume of antibiotic use, possibly reducing the risk of healthcare-associated complications
and infections. It identified many patients who could potentially have been managed in the community with appropriate resources, saving 481 bed-days. The health economics are reported in a companion paper.
Keywords: antibiotic treatment, hospital length of stay, OPAT, patient pathway