Overuse of broad-spectrum antibiotics in secondary care is a key contributor to the emergence and spread of antimicrobial resistance (AMR); efforts are focused on minimizing antibiotic overuse as a crucial step toward containing the global threat of AMR. The concept of overtreatment has, however, been difficult to define. Efforts to address the overuse of medicine need to be informed by an understanding of how prescribers themselves understand the problem. We report findings from a qualitative interview study of 46 acute care hospital prescribers differing in seniority from three countries: United Kingdom, Sri Lanka and South Africa. Prescribers were asked about their understanding of inappropriate use of antibiotics. Prescriber definitions of inappropriate use included relatively clear-cut and unambiguous cases of antibiotics being used “incorrectly” (e.g., in the case of viral infections). In many cases, however, antibiotic prescribing decisions were seen as involving uncertainty, with prescribers having to make decisions about the threshold for appropriate use. Decisions about thresholds were commonly framed in moral terms. Some prescribers drew on arguments about their duty to protect public health through having a high threshold for prescribing, while others made strong arguments for prioritizing risk avoidance for the patients in front of them, even at a cost of increased resistance. Notions of whether prescribing was inappropriate were also contextually dependent: high levels of antibiotic prescribing could be seen as a rational response when prescribers were working in challenging contexts, and could be justified in relation to financial and social considerations. Inappropriate antibiotic use is framed by prescribers not just in clinical, but also in moral and contextual terms; this has implications for the design and implementation of antibiotic stewardship interventions aiming to reduce inappropriate use of antibiotics globally.

Background: Low blood pressure and associated postural symptoms are well-recognized manifestations of anaphylaxis. Nonetheless, anaphylaxis can present with high blood pressure and is rarely reported in the literature. We report an unusual presentation of anaphylaxis with severe supine hypertension and orthostatic intolerance. Case presentation: A 43-year-old Asian female presented to the emergency department with generalized itching, hives, and postural dizziness after taking a slow-release diclofenac sodium 100 mg tablet. On admission, the patient was tachycardic with a supine blood pressure of 200/100 mmHg. She had urticaria and bilateral rhonchi. A clinical diagnosis of anaphylaxis was made. She was treated with intravenous hydrocortisone and chlorpheniramine, but intramuscular adrenaline was withheld owing to her high blood pressure. She was kept in the supine position, and her vital parameters were closely monitored. Although the respiratory and cutaneous symptoms improved with treatment, her blood pressure remained elevated. Forty minutes later, the postural dizziness recurred as she sat up on the bed and her blood pressure plummeted from 198/100 mmHg to 80/60 mmHg. She was put back in the supine position immediately, and the blood pressure was restored with three doses of intramuscular adrenaline and a fluid bolus. Her postural symptoms completely resolved after adrenaline, but her blood pressure remained elevated. Two weeks after the initial presentation, a diagnosis of essential hypertension was made, which probably had been undetected. In anaphylaxis, where the cardiovascular system is involved, a blood pressure reduction from baseline is expected in patients with preexisting hypertension. Despite cardiovascular involvement, our patients’ blood pressure on presentation to the emergency department was much higher than her pretreatment ambulatory blood pressure, thus making this presentation unusual. Conclusions: Diagnosis and treatment of anaphylaxis can be delayed in patients presenting with high blood pressure. Postural symptoms should alert the clinician to cardiovascular involvement despite elevated supine blood pressure. Early treatment with adrenaline should be considered in these patients with extreme caution.

Introduction Carbapenems are used to treat multidrug-resistant organisms as last-resort antibiotics. Resistance to carbapenems is an emerging public health threat worldwide, with alarming reported rates in Asian countries. To minimise further spread of resistant strains and guide interventions, it is important to understand the prevalence rates and causative molecular determinants. Therefore, the systematic review and meta-analysis arising from this protocol will aim to comprehensively describe the available surveillance data on carbapenem resistance in Asian countries to provide an in-depth overview of the carbapenem resistance status in this region. Methodology and analysis A systematic review and meta-analysis will be conducted via PubMed, ScienceDirect, Cochrane Library and Web of Science databases. Additional articles and grey literature will be searched in Google Scholar, OpenGrey and Google Chrome by manually searching the reference lists of selected studies. The review question was designed according to components in the ECLIPSE (E-expectations, C-client, L-location, I-impact, P-profile and S-service) framework. Studies conducted with samples other than clinical samples will be excluded. Only original articles published in the English language will be included. The Joanna Briggs Institute critical appraisal tool will be used to assess the quality of the included studies. A random-effects meta-analysis will be performed if the data are sufficiently homogenous. Heterogeneity between studies will be assessed via the I² statistic. The subgroup analysis will be performed considering the type of sample, pathogen type, region/country where the studies were conducted and genetic determinants. Ethics and dissemination As this study is conducted on the basis of published data, ethical approval is exempt. The findings of this study will be disseminated in a peer-reviewed journal with the intention of providing summarised data on the globally emerging threat of carbapenem resistance and emphasising the need to introduce alternative, more effective treatment options. PROSPERO registration number CRD42024515806.

Introduction: A laboratory request form is an important mode of communication between the clinician and the laboratory. Accurate information provided in a microbiology request form is useful in identifying errors in the preanalytical stage, making decisions in the analytical stage, and interpreting results in the post-analytical stage of specimen processing. This study aims to describe the degree of incompleteness of microbiology laboratory requests at a university hospital in Sri Lanka.Methods: All urine and blood culture request forms received by the microbiology laboratory during a 6-month period were studied. Each request was assessed for the completeness of the information requested on the form.Results: Of 2087 request forms, none were filled completely. The patient’s name was present in all request forms, while the age and gender were absent in 37 (1.8%) and 380 (18.2%) respectively. The location of the patient was not given in 380 (18.2%). Clinical information of the patient with a short clinical history and details of antibiotics were missing in 840 (40.2%) and in 1665 (79.7%) respectively. A high rate of incompleteness was seen in specimen details such as the date (1479, 70.8%) and time of specimen collection (2011, 96.3%). The clinician’s name and designation were lacking in 1457 (69.8%) and 1110 (53.1%) respectively, while the signature was not available only in a few, 131 (6.3%,).Conclusion: Manual completion of microbiology laboratory request forms was not satisfactory. Details mainly lacking were related to specimen collection, clinical details, and clinician details. Poor documentation on request forms may lead to incorrect reporting and/or interpretation of results, and delays in reporting. Implementation of an electronic request form with mandatory components through an Electronic Medical Record (EMR) system incorporated into a Laboratory Information Management System (LIMS) is an alternative that would correct these gaps, minimise errors, and enhance the quality of reporting in microbiology diagnostic laboratories.

Introduction: Facing a pandemic is quite challenging for resource-poor healthcare settings. As the COVID-19 pandemic unfolded, healthcare workers (HCWs) had to work with insufficient skills, knowledge and experience regarding the novel coronavirus, which increased their risk of infection. Methods: This study aimed to determine the personal protective equipment (PPE) usage, exposure characteristics, clinical outcomes and seroprevalence of SARS-CoV-2 antibodies among a group of quarantined HCWs in seven hospitals in the Western province of Sri Lanka, during the first wave of the pandemic. Data were collected using an intervieweradministered questionnaire and a serum sample was collected at six weeks of exposure to detect SARSCoV- 2 specific IgG antibodies. Both descriptive statistics and chi square test were performed to identify distribution patterns and associations. Results: Of 167 quarantined HCWs, 89(53.3%) had high-risk exposures, while 78 (46.4%) reported lowrisk exposures. Eighty-four HCWs have been exposed when interacting with the patient’s environment and 90.5% of them were not using recommended PPE. None of the HCWs wore N95 or higher respirators when performing aerosolgenerating procedures. SARS-COV-2 RT-PCR assay was performed only on 117 (70.1%) HCWs, with 49.6% of them being subjected to the test after 14days of exposure. SARS-CoV-2 specific IgG antibodies were detected in 31(18.6%) HCWs. A high seroprevalence was observed among HCWs over 40 years (n=13, 29.5%) (P=0.029). Conclusions: This study illustrated an imperfect adherence to PPE recommendations and high transmission of COVID-19 amongst HCWs. The observed inappropriate use of RT-PCR assay and unwarranted quarantining of HCWs in a limited resource setting is concerning.