Antimicrobial prescribing in dentistry contributes to approximately 10% of overall antibiotic prescribing in primary care, which is significant. There is an opportunity to enhance antimicrobial stewardship (AMS) in dentistry practice in Ireland to address this. In order to understand the factors influencing antimicrobial prescribing by dentists, their views and experiences must be explored. To conduct a mixed methods study to explore general dental practitioner’s views and experiences regarding antimicrobial use and antimicrobial resistance (AMR). An explanatory sequential mixed methods study was conducted. First, a survey exploring dental antimicrobial prescribing and views on antimicrobial prescribing and AMR was emailed to Irish Dental Association members in September 2024. The survey findings were analysed descriptively. The findings helped to refine the topic guide of the subsequent qualitative, semi-structured interviews conducted with general dental practitioners in November/December 2024. The verbatim interview transcripts were analysed by thematic analysis (Braun and Clarke) and then mapped to the Theoretical Domains Framework. Ethics approval was obtained, and all participants provided written informed consent. A total of 79 survey responses (62% female) were obtained and 12 interviews (six female) were conducted. The survey found that 45 (57%) dentists referred to the national health service antibiotic prescribing guidelines. Many dentists felt antibiotics are overprescribed in dentistry (61/78, 78.2% agree/strongly agree) and 59 (74.7%) agree/strongly agree that patients often expect to be prescribed an antibiotic. The results found that 41% (32/78) of respondents reported they never calculate a weight-based antibiotic dose for a child. The main domains reported were knowledge, environmental context and resources, memory, attention and decision-making, beliefs about consequences, beliefs about capabilities, social influence and social/professional role. Dentists reported the pressure from patients to prescribe antibiotics and also the lack of time to review and intervene on patients with infection. ‘Just in case’ antibiotic prescribing was noted in the survey and interview findings. Dentists interviewed noted the challenge when making decisions for infections not responding to the initial course of antibiotics and communicating with patients where English is not their first language. Challenges in dental interventions, or antibiotic compliance, in children or those with special needs were also noted as impacting on decisions. Many highlighted the importance of continuing professional development (CPD) and audits to improve antimicrobial prescribing practices. This study identified important social and contextual factors in general dental practice which influence the prescribing of antimicrobials. To support the development of AMS in dental practice it is important to engage with dentists to ensure initiatives are tailored to their setting. CPD for dentists, patient education and surveillance of antibiotic prescribing in dental practice are recommended.

Background:Efforts to address overuse of antibiotics for RTIs are important to limit antimicrobial resistance. Leaflets used during GP consultations can empower patients to self-manage respiratory infections (RTIs) and support a reduction in unnecessary antibiotic prescribing. Objectives:This study aimed to assess the feasibility and acceptability of a Treat Your RTI (TY-RTI) patient leaflet for GP consultations in Ireland. Methods:A single-arm mixed-methods feasibility study was conducted. Six GPs in daytime practice and three GPs in out-of-hours (OOH) services were recruited to use the TY-RTI leaflet during routine RTI consultations where an immediate antibiotic was not deemed necessary. GPs and patients completed questionnaires to assess the feasibility and usefulness of the leaflet during the consultation. Ethical approval was obtained. Results:The TY-RTI patient leaflet was used by GPs in 201 RTI consultations (57 in OOH, 28%), and 84 (42%) patients/parents completed the questionnaire (9/84 in OOH, 11%). For over 90% (182/201) of consultations, GPs reported the leaflet was useful, supported communication, safety-netting, and did not increase consultation time. All patients/parents found the leaflet easy to read and useful. They reported the leaflet gave them confidence to self-manage RTIs without antibiotics (88%, 74/84), and it changed their views of the need for antibiotics (81%, 68/84). Conclusions:This study demonstrates the feasibility and acceptability of the TY-RTI leaflet for GPs and patients, supporting its wider implementation. The leaflet supports improved communication and safety netting in the consultation and empowers patients in the self-management of RTIs, with potential to reduce patients' antibiotic-seeking behavior.

Infectious diseases (ID) pose ongoing challenges within healthcare, requiring a multidisciplinary approach to patient management. ID pharmacists play an essential role in the provision of a variety of ID services, ensuring the safe and appropriate delivery of pharmaceutical care. While insights into this role have been described internationally, the role of the ID pharmacist remains underdefined in the Irish context. To explore the experiences, roles and scope of practice of pharmacists providing ID services in Irish hospitals. Semi-structured interviews were conducted with pharmacists working in ID services in Irish hospitals in November 2024. Thematic analysis was used to identify themes in interview transcripts. Ethical approval and written informed consent were obtained. Sixteen pharmacists were recruited from twelve different hospitals across Ireland. Within the sample there was variety in gender, age, years of experience, and roles. Predominant themes included the broad scope of the role and responsibilities of ID pharmacists, the positive impact of ID pharmacists, barriers and challenges in the role such as staffing shortages, lack of facilities and workload, future aspirations and comparison to international standards, including the role of the pharmacy technician. Pharmacists play a crucial role in medication management, patient counselling, and multidisciplinary collaboration. However, inadequate formal recognition, the absence of structured ID training, the importance of interprofessional collaboration and management of ID patients in hospitals without a specific ID service were raised. Pharmacists expressed a strong desire for independent prescribing rights and pharmacist-led ID clinics, aligned with international models. This study provides an in-depth insight into the scope and impact of the pharmacist in ID services in Ireland. While pharmacists contribute substantially to ID patient care, challenges around staffing levels, resource limitations and workload pressures that limit their full integration into healthcare teams need to be addressed. Expanding their role through policy changes, structured training, and independent prescribing could enhance patient outcomes and align Ireland with international best practices. These findings should inform future service development to advance the pharmacist role in ID services and ensure integration of the role in the health service.

Abstract Introduction The use of Point of Care Testing (POCT) as an aid to guide antibiotic prescribing has been highlighted in Ireland’s second One Health National Action Plan on Antimicrobial Resistance 2021-2025 (iNAP2).[1] The role of community pharmacy is expanding with the introduction of antimicrobial stewardship (AMS) POCT strategies. Uncomplicated urinary tract infections (UTIs) are frequent and burdensome in the community. With antibiotic resistance on the rise amongst uropathogens, AMS efforts to reduce inappropriate antibiotic prescribing for urinary symptoms are paramount. Aim To evaluate community pharmacy staff views and experiences on the provision of a Cystitis Test-and-Treat Service for uncomplicated UTIs, while identifying opportunities for service improvement and expansion. Methods An electronic survey on Microsoft® Forms was distributed within a large retail pharmacy chain in Ireland during November 2021, with two reminders issued. Pharmacists and Healthcare advisors over the age of 18, working in 88 pharmacies that provided the Velieve Cystitis Test-and-Treat Service were eligible to participate. The survey was subdivided into participant demographics, local UTI information, views and experiences of participants on the Cystitis Test-and-Treat Service, the patient information leaflet and the training completed by pharmacy staff providing the service and included open-ended and closed-ended or Likert-scale questions. The survey was developed based on the literature and was revised following the contributions of pharmacy chain pharmacists and its Research Governance Committee who have a working knowledge of Service. Data were analysed using Microsoft® Excel and IBM® SPSS® statistics version 28.0. Qualitative data from the open-ended survey questions were analysed using thematic analysis. Results A total of 43 pharmacy staff (18 pharmacists and 25 healthcare advisors) participated in the study (overall participation rate of 10.2%). The majority of participants were female (83.7%) and most pharmacies were located in a town/suburb area (55.8%). The majority of participants (76.7%) estimated that service users with symptoms suggestive of UTI present to the pharmacy first, before visiting their GP. Participants believed that the Cystitis Test-and-Treat Service improved service user satisfaction in symptom management, reduced antimicrobial prescribing, alongside reduced general practitioner workload. High acceptability was attributed to the speed and convenience of the service, while time cost and time required explaining the service were identified as barriers. The associated smartphone application was identified as a service weakness. Participants recommended extended training on service user eligibility with perhaps training videos to improve overall confidence. While the low response rate and small sample size is a limitation of this study, the inclusion of participants from two differing pharmacy roles strengths the findings. Conclusion This study highlights that POCT are feasible AMS initiatives that enhance management of uncomplicated UTI and could be incorporated into community pharmacy practice. The perceived ‘poor public awareness of the service’ reported by the participants, suggests the need for increased promotion and advertising. References 1. Government of Ireland (2021). Ireland’s One Health National Action Plan on Antimicrobial Resistance 2021 – 2025. Available from: https://www.gov.ie/en/publication/d72f1-joint-action-on-antimicrobial-resistance/

ObjectivesThe use of parenteral systemic anticancer therapy (SACT) has led to improved cancer survival. A quality assurance (QA) system of the aseptic compounding process is necessary to ensure safe and consistent production of parenteral SACT. This scoping review identifies international evidence and practice relating to QA standards in the preparation of parenteral SACT in healthcare establishments.MethodsStandards relating to aseptic compounding in hospital pharmacies and literature exploring the aseptic compounding of parenteral SACT were included. Literature relating to the non-aseptic compounding of medicines and records specific to sterile manufacturing in industrial settings were excluded. A search of several electronic databases, trial registries, the grey literature and websites of key European hospital pharmacy groups and accreditation bodies was conducted on 16 March 2022. A narrative discussion was performed by country, and content analysis of articles was conducted.ResultsThirty-seven records were included. Standards reviewed covered the work environment, the preparation process and the safety of the workers who are potentially exposed to hazardous chemicals. It was a common practice to include frequent audits to ensure adherence to standards. Some standards also recommended external inspections to allow for further learnings. Periodic reviews are encouraged to ensure standards maintain relevance. National standards of the countries reviewed were based on international standards, with minor adaptations for local conditions.ConclusionsThe main limitation of this review is that it is limited to countries with a high human development index. The review shows that the use of an internationally recognised standard as a basis for national standards is best practice, and will allow for relevance into the future.

Abstract Introduction Surveillance of antibiotic use is a key part of Ireland’s National Action Plan for Antimicrobial Resistance 2021-2025. A higher proportion of patients are reported to be prescribed antibiotics in out-of-hours (OOH) doctors services compared to daytime general practice.[1] Challenges with antibiotic prescribing in this setting include unfamiliarity between doctor and patient, lack of follow-up, access to medical history and diagnostics. Surveillance of antibiotic use in OOH services is important to develop tailored antimicrobial stewardship (AMS) interventions in this setting. In Ireland, a national Preferred Antibiotic Initiative encourages prescribers in community settings to avoid, where possible, a list of Red (less preferred) antibiotics, and choose from a Green (preferred) list, if an antibiotic is required. Aim To evaluate antibiotic prescribing patterns in OOH services in the Cork/Kerry region to inform future AMS interventions and to ascertain trends in prescribing of Red antibiotics. Methods A retrospective, observational study was conducted of all oral antibiotic prescriptions in OOH doctors’ consultations between 1st December 2019 and 31st December 2021 in the region. Data were gathered on age, gender, date and time of consultation, consultation method (in person, remote), antibiotic and its indication. Data were analysed using Microsoft Excel v2018 and SPSS v28. Results Overall, 17% (69,017 of 406,812) of the OOH doctors’ consultations resulted in an antibiotic prescription, with considerable variation over the study period just prior to and during the COVID-19 pandemic, ranging from 31% in December 2019 to less than 2% in April 2020 and 22% in December 2021. During the COVID-19 pandemic part of the study period (April 2020 to December 2021), 66% of antibiotics prescribed were from remote consultations, prior to which antibiotic prescribing from remote consultations was rare. Of the antibiotics prescribed, 21% were in children under 6 years old. Respiratory tract infections (RTIs) were the most common indication for antibiotics (60%). Amoxicillin was the most commonly prescribed antibiotic (40% of all prescriptions). Red (reserved) antibiotics accounted for 19% of all prescriptions, which is substantially lower than national figures reported for the study period (35-45%)[2] and the national target of less than 34% for 2021. Red antibiotics were more commonly prescribed during the overnight shifts and in older adults, and less commonly prescribed in remote consultations. Conclusion Low antibiotic prescribing levels during the early stages of the pandemic were not sustained. Antibiotic prescriptions from remote consultations were common. Red antibiotic prescribing proportion is lower than the national mean in this OOH service. Key opportunities for AMS are addressing the volume of antibiotic prescribing for RTIs, particularly in children, AMS in telemedicine and the higher proportion of Red antibiotics prescribed by the overnight shift doctors. This is the first study describing indications antibiotic prescriptions in the OOH setting in Ireland. A limitation of this study is clinical presentation was not available for all OOH consultations. This would have given opportunity to assess the proportion of infectious presentations resulting in an antibiotic prescription to identify further of areas for AMS intervention. References 1. Edelstein M, Agbebiyi A, Ashiru-Oredope D et al. Trends and patterns in antibiotic prescribing among out-of-hours primary care providers in England, 2010-14. J Antimicrob Chemother. 2017; 72: 3490-3495 2. Antimicrobial Resistance and Infection Control Team, Ireland. PCRS Greed Red Report September 2021. Available from: https://www.hse.ie/eng/services/list/2/gp/antibiotic-prescribing/safe-prescribing/pcrs-green-red-report-09-2021-positive-trends-and-introduction-of-rate.pdf

Abstract Introduction Future healthcare workers’ education must include antimicrobial stewardship (AMS) clinical decision-making to achieve optimal clinical outcomes and to treat and prevent infection in a manner that minimises the effects of antimicrobial resistance (AMR) and is safe for patients. Clinical reasoning is an important cognitive process that is essential to evaluate and manage a patient’s medical problem.[1] This study aimed to evaluate the cognitive processes and clinical reasoning skills of pharmacy students when they review AMS cases, as well as identify any existing knowledge gaps in this area that need to be addressed. Methods This qualitative study used a case study approach, in which a sample (n=13) of Master of Pharmacy (MPharm) students in an Irish University were recruited to interpret three patient infection cases. Convenience sampling of MPharm students by email invitation was conducted and students took part voluntarily. Semi-structured interviews were conducted, recorded and transcribed verbatim. A think-aloud procedure with verbal protocol analysis was adopted to determine students’ decision-making processes and clinical reasoning.[2] Thematic analysis was used to analyse interview data. Results Interviews were conducted with 13 students (5 male, 8 female), all aged 22-27 years old. Overall, students interpreted and reasoned through the cases following a structured approach. Some students adopted different approaches to clinical decision-making and did not always follow all the steps outlined in the clinical reasoning cycle. Within the clinical decision-making process, common themes were identified, as outlined in Table 1. Some knowledge gaps were reported by students, including antibiotic prophylaxis, microorganisms, AMS measures, guideline use, soft tissue infection management, and IV-to-oral switch. Conclusion This study provides interesting findings on students’ interpretation and review of infection management and AMS principles which could inform the curriculum development of pharmacy education in AMR and AMS. Educators should consider introducing opportunities to develop clinical reasoning skills to support learning on AMS concepts, particularly in challenging areas such as microbiology, and interpretation and application of guidelines. A limitation of the study is that it was conducted with pharmacy students from one university programme. A strength of the study is the think-aloud methodology which provides in-depth detail on students clinical reasoning thought processes and skills. References 1. Wright DF, Anakin MG, Duffull SB. Clinical decision-making: an essential skill for 21st century pharmacy practice. Research in Social and Administrative Pharmacy. 2019;15(5):600-6. 2. Pinnock R, Fisher TL, Astley J. Think aloud to learn and assess clinical reasoning. Medical Education. 2016;50(5):585–6.

Background Respiratory tract infections (RTIs) are the most common reason for prescribing antibiotics in general practice. The COVID-19 pandemic has impacted on antibiotic prescribing and delivery of primary care in Ireland. Objectives To assess the quality of antibiotic prescribing, the impact of the COVID-19 pandemic and identify opportunities for antimicrobial stewardship (AMS) in Ireland. Methods Point prevalence audit surveys for RTI consultations were conducted as part of a European study at three time periods: January-February 2020, March-May 2020 and March-May 2021. Antibiotic prescribing was assessed and comparisons made between the three time periods. Results In total, 765 consultations were recorded, which were mainly face to face before the pandemic, but changed to predominantly remote consultations during the pandemic surveys in 2020 and 2021 (82% and 75%). Antibiotics were prescribed in 54% of RTI consultations before the pandemic. During pandemic surveys, this dropped to 23% in 2020 and 21% in 2021. There was a decrease in prescribing of Red (reserve) agents in 2021. Assessment against indication-specific quality indicators showed a high proportion of consultations for bronchitis and tonsillitis resulting in an antibiotic prescription (67% and 85%). Point-of-care testing (POCT) to aid diagnosis of RTIs were utilized in less than 1% of consultations. Conclusions During the COVID-19 pandemic, there was a reduction in antibiotic prescribing. Opportunities identified to support AMS in primary care in Ireland are targeted initiatives to reduce antibiotic prescribing for bronchitis and tonsillitis and introducing POCT to support appropriate antibiotic prescribing.

Background Infections are a common reason for patient consultation in out-of-hours (OOH) doctors’ services. Surveillance of antibiotic prescribing in OOH settings is important to develop tailored antimicrobial stewardship (AMS) interventions. Objectives To evaluate antibiotic prescribing patterns in OOH services in the Cork Kerry region, Ireland to inform future AMS interventions. Methods A retrospective, observational cohort study was conducted of all oral antibiotic prescriptions in OOH doctors’ consultations between 1 December 2019 and 31 December 2021 in the region. Data were gathered on age, gender, date and time of consultation, consultation method (in person, remote), antibiotic and its indication. Data were analysed using Microsoft Excel v.2018 and SPSS v.28. Results Overall, 17% (69 017 of 406 812) of the OOH doctors’ consultations resulted in an antibiotic prescription during the study period. This varied from 31% of OOH consultations in December 2019 to less than 2% of OOH consultations in April 2020. Of the antibiotics prescribed, 21% were for children under 6 years old. Respiratory tract infections (RTIs) were the most common indication for antibiotics (59%). Amoxicillin was the most commonly prescribed antibiotic (40% of all prescriptions). Red (reserved) antibiotics accounted for 19% of all prescriptions. During the COVID-19 pandemic period of the study, 66% of 49 421 of antibiotic prescriptions were issued from remote consultations. Conclusions Low antibiotic prescribing levels during the early stages of the pandemic were not sustained. Antibiotic prescriptions from remote consultations were common. A key opportunity for AMS is addressing the volume of antibiotic prescribing for RTIs, particularly in children.

Abstract Background The most commonly reported infections in older persons’ long-term care facilities (LTCFs) are urinary tract infections (UTIs). UTIs contribute to high rates of antimicrobial prescribing, for the treatment and prophylaxis of UTI. Antimicrobials are often inappropriately prescribed and can increase the risk of antimicrobial resistance and other negative outcomes in LTCF populations.1 Objectives To explore the views and experiences of nurses and doctors working in LTCF on the management of UTIs. Methods Qualitative, semi-structured interviews were conducted with nurses and GPs who work in or provide medical service in LTCFs in November 2022. Interviews were conducted online or by telephone, and recordings transcribed. Thematic analysis was conducted, and the themes were mapped to the Theoretical Domains Framework (TDF)1.2 Results Seven nurses and eight GPs were interviewed. Key domains such as knowledge, memory, attention and decision making and beliefs about consequences had an influential role on UTI management as reported by participants. Contextual factors such as the time taken to obtain urine culture results, and social factors such as the key role of the LTCF nurse, were reported as key issues. Variability in practice and inconsistent knowledge of urine dipstick and UTI management guidelines were acknowledged in the management of UTIs and urine dipstick practices between participants. Conclusions This study identified social factors, contextual LTCF factors and variability in the management of UTI and urine dipstick practices across the participants. LTCFs require improved access to urine culture results, improved communication between all healthcare professionals involved and increased implementation of dipstick and UTI management guidelines.

Abstract Background Antimicrobial stewardship (AMS) is essential to control the emergence of antimicrobial resistance (AMR) which has become an international health priority. Education of undergraduate students on AMS and AMR is a strategic objective in the WHO Global Action Plan on AMR and Ireland's National Action Plan.1,2 Research on AMS/AMR education has focused primarily on medical students with less emphasis on those from other healthcare profession including pharmacy students. Objectives To investigate AMS and AMR education in the Pharmacy undergraduate programme in the School of Pharmacy of an Irish University. Methods A mixed methods study was conducted. Ten semi-structured interviews were conducted in October 2019 with academic staff to capture their views on AMS education. Participants included staff members from different disciplines, those identified as involved in teaching elements of infectious disease, antibiotics, AMS and related topics, and those involved in curriculum design and approval within the School of Pharmacy. Interview transcripts were analysed by thematic analysis. An electronic survey of 17 questions was emailed to all second to fifth year UCC Pharmacy students in October 2019 to gather students’ views and experiences of AMS education. The survey contained four sections which addressed demographics, AMS, resources and education using open-ended, closed-ended or Likert-scale questions. Ethical approval was obtained. Results Six key themes were identified from the ten interviews: (i) curriculum priorities and capacity; (ii) housing of the subject, fragmentation and cohesion; (iii) integration; (iv) communication; (v) teaching methods; and (vi) assessment methods. 113 students participated in the survey (32.3% response rate). 96% agree that a strong knowledge of antimicrobials for their future careers is important, and over 89% of students desire more education on AMR and AMS. Only 43% of students found their AMS education provided sufficient preparation for practice. Students felt most prepared to recognize clinical signs of infection and least prepared for IV to oral switching, interpreting biological marker and de-escalation of antimicrobials. Over 50% of students never used or were not familiar with the national primary care antimicrobial guidelines: www.antibioticprescribing.ie. Conclusions Pharmacy students and staff agree that AMS and AMR are important and need enhanced educational focus. Students feel there are gaps in their AMS education and expressed a desire for more education in this area. Improved communication and identification of curriculum priorities by staff could help to establish a more cohesive and comprehensive educational approach to this area.

Abstract Background Education of undergraduate healthcare professionals (HCPs) on antimicrobial stewardship (AMS) and antimicrobial resistance (AMR) is recommended as an important strategy to prepare future HCPs for their roles in these areas.1 There is limited qualitative research investigating the views of clinical and academic staff involved in the teaching of undergraduate HCP students on current AMS/AMR education practices and curricula. Objectives To explore the views and experiences of clinical and academic staff involved in HCP and public health programmes on AMS and AMR education. Methods A qualitative study using semi-structured interviews was conducted in October to December 2020. The interview participants were purposively sampled to recruit clinical or academic staff involved in education of students on undergraduate HCP programmes (dentistry, medicine, nursing and midwifery, pharmacy) and public health programmes in an Irish university. Participants were asked to outline their views on current teaching and assessment methods, use of AMS competency frameworks and potential areas for improvement. Interview recordings were conducted online, the recordings were transcribed verbatim, and transcripts analysed by thematic analysis. Ethical approval was obtained, and all participants provided written informed consent. Results Interviews were conducted with 15 participants (10 female). A range of disciplines were represented as outlined in the methods. The main interview themes included the challenge of balancing curriculum priorities and capacity in HCP programmes, the importance of ensuring student understanding of AMS/AMR principles, and patient centred application of knowledge. Current teaching and assessment methods were found to vary between the HCP programmes with a mix of didactic lectures and workshops, and assessment ranging from written exams and multiple choice questions to observed structured clinical exams. Very few participants reported educating different HCP students together. Participants were asked to review an antimicrobial education competency framework,2 with most participants believing that this would improve the structure of AMS education, ensuring that key learning outcomes would be addressed in the curriculum. The importance of preparing students for interprofessional practice in AMS in the future was identified as a key theme, with participants highlighting the importance of interprofessional education opportunities to foster communication and teamwork skills in AMS at an early stage. Conclusions The importance of AMS and AMR education in HCP programmes was reported in this study, however the main challenge is limited curricular space in busy HCP programmes. Education may be improved by aligning AMS education with an appropriate competency framework. Enhancement of undergraduate interprofessional education opportunities, to prepare students for interprofessional AMS in future practice, is recommended.