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UKHSA co-lead: Dr Julie Robotham

Oxford University co-lead: Professor Christopher Butler 


The strategy is to exploit multi-disciplinary approaches to complex interventions, including behaviour change techniques, mathematical modelling and WGS, to answer the following key questions: 

  1. How can antibiotic prescribing in primary care be sustainably reduced to the minimum safe level?
  2. How can national, hospital and patient-focused approaches be integrated to improve management and outcomes for AMR&HAI?



Model-based evaluation of hospital admission screening strategies for CPE 

We built model-based simulations of hospitals, with CPE prevalence covering the range of levels observed in England, and used these to evaluate the existing national CPE admission screening guidelines and alternatives to. Two beneficial guideline changes were identified: 1) broadening screening selection criteria to include all admissions who had been hospital inpatients anywhere in the last year, 2) shortening the screening test pathway to a single, rather than three consecutive, swabs.  

We found these changes to be both clinically and operationally desirable: more previously unidentified CPE-carriers entering hospital would be selected for testing, and the shorter optimised testing pathway means status would be known more rapidly, importantly increasing the chance this would be prior to hospital discharge, without unduly compromising overall sensitivity/specificity. 


Conduct trial and qualitative work investigating the provision of new point-of-care tests for RTIs in community care  

We are contributing our qualitative expertise to develop and conduct a study investigating views on POCT as part of the EU VALUE-Dx project ( which aims to build the medical and economic case for rapid diagnostics as a public good in the fight against antibiotic resistance, focussing on the management of community-acquired respiratory tract infections in European community care.  


Investigating impact of plasmid dynamics on CPE surveillance and control  

Theoretical and data-driven approaches are currently being used to understand plasmid evolution and plasmid-mediated AMR spread in Enterobacteriales. A PhD student is looking at Plasmid-mediated Carbapenemase-Producing Enterobacterales (CPE) outbreaks to understand outbreak characteristics and predicting public health risk.


Network modelling for nowcasting, forecasting and intervention evaluation at an individual level  

We have developed a protocol and initiated a phased approach to this project, with the short-term objective to: (1) Develop and calibrate an individual-based spatially explicit dynamic network model (building on work from the last HPRU) to allow simulation of CPE spread across the NHS referral network that supports nowcasting, forecasting and scenario analysis. Longer-term objectives are to: (2) Establish real-time trust-level data feeds for key model inputs including: patient movements, microbiological test results, antibiotic use, infection control measures in operation, and aspects of building design that potentially impact on transmission (3) Develop a Dashboard interface to enable healthcare professionals to interact with model output (4) Develop innovative approaches to ensure the model and control policies address health inequalities (5).Using the modelling framework, evaluate the potential benefit of different intervention measures (including screening and isolation strategies), considering both effectiveness and cost-effectiveness (6) Perform in silico evaluations of the potential benefits from incorporating additional types of surveillance data including genomic data into the proposed analysis.  


Exploring antibiotic choice and associated implications  

We have designed a stated preference study (determining what people say they will do) to investigate which clinical factors drive prescribing decision-making post-COVID-19. Through literature review and a ranking exercise with GPs we have identified key attributes to be included in a discrete choice experiment.   

Alongside this, we are conducting a revealed preference study (to determine what people actually do) exploring predictors of actual infection-related primary care prescribing using CPRD data. Combining stated and revealed preference data, we plan to enhance predictions of behavioural change from introducing interventions influencing drivers of antibiotic choice, inform intervention design and implementation.   


Qualitative and quantitative investigation “Stopping antibiotics when patients feel better” as a mechanism to reduce overall antibiotic exposure  

The research has involved both a qualitative study with clinicians and patients to explore their views on the advice to stop antibiotics when patients feel better and a quantitative mathematical modelling study investigating the impact of stopping antibiotics when better on treatment success as well as resistance development. We are also currently combing the results of these two studies in the context of current evidence and outlining future research directions.  


Qualitative evaluation of Acute Respiratory Infection Hubs Implementation (ARIHI) as a mechanism to reduce antibiotic prescribing  

This is on ongoing qualitative study to explore the implementation of Acute Respiratory Infection (ARI) hubs in England; it involves interviews with professionals involved in setting up, managing and providing care in ARI hubs to understand the role of ARI hubs in managing ARIs and barriers and facilitators to implementation. 



Interventions Theme Publications

Prospective trial of different antimicrobial treatment durations for presumptive canine urinary tract infections

Allerton F, Pouwels K, Bazelle J, Caddy S, Cauvin A, De Risio, Swann J, Warland J, Kent A


Investigating the mechanism of impact and differential effect of the Quality Premium scheme on antibiotic prescribing in England: a longitudinal study

Anyanwu P, Pouwels K, Walker A, Moore M, Majeed A, Hayhoe B, Tonkin-Crine S, Borek A, Hopkins S, Mcleod M, Costelloe C


Social and contextual influences on antibiotic prescribing and antimicrobial stewardship: A qualitative study with clinical commissioning group and general practice professionals

Borek AJ, Anthierens S, Allison R, Mcnulty CAM, Anyanwu PE, Costelloe C, Walker A, Bulter C, Tonkin-Crine S, STEP-UP Study Team


STEP-UP study team. Implementing interventions to reduce antibiotic use: a qualitative study in high-prescribing practices

Borek A, Campbell A, Dent E, Butler C, Holmes A, Moore M, Walker A, Mcleod M, Tonkin-Crine S, STEP-UP Study Team


Optimising antimicrobial stewardship interventions in English primary care: a behavioural analysis of qualitative and intervention studies

Borek A, Wanat M, Akins L, Sallis A, Ashiru-Oredope D, Beech E, Butler C, Chadborn T, Hopkins S, Jone L, McNulty C, Robert N, Shaw K, Taborn E, Tonkin-Crine S


How did a Quality Premium financial incentive influence antibiotic prescribing in primary care? Views of Clinical Commissioning Group and general practice professionals?

Borek A, Anthierens S, Allison R, McNulty C, Lecky D, Costelloe C, Holmes A, Butler C, Walker A, Tonkin-Crine S,


Development of an intervention to support the implementation of evidence-based strategies for optimising antibiotic prescribing in general practice

Borek A, Campbell A, Dent E, Moore M, Butler CC, Holmes A, Walker AS, Mcleod M, Tonkin-Crine S, Anyanwu PE, Borek AJ, Bright N, Buchanan J, Butler CC, Campbell A, Costelloe C, Hayhoe B, Holmes A, Hopkins S, Majeed A, Mcleod M, Moore M, Morrell L, Pouwels KB, Robotham JV, Roope LSJ, Tonkin-Crine S, Walker AS, Wordsworth S, Wright C, Yadav S, Zalevski A


Impact of the COVID-19 Pandemic on Community Antibiotic Prescribing and Stewardship: A Qualitative Interview Study with General Practitioners in England

Borek A, Maitland K, Mcleod M, Campbell A, Hayhoe B, Butler C, Morrell L, Roope L, Holmes S, Walker A, Tonkin-Crine S, STEP-UP Study Team


Preferences for Medical Consultations from Online Providers: Evidence from a Discrete Choice Experiment in the United Kingdom

Buchanan J, Roope L, Morrell L, Pouwels K, Robotham J, Abel L, Crook D, Peto T, Butler C, Walker A, Wordsworth S


Following the science? Views from scientists on government advisory boards during the COVID-19 pandemic: a qualitative interview study in five European countries

Colman E, Wanat M, Goossens H, Tonkin-Crine S, Anthierens S


Understanding how community antiretroviral delivery influences engagement in HIV  are: a qualitative assessment of the Centralised Chronic Medication Dispensing and Distribution programme in South Africa

Dorward J, Msimango L, Gibbs A, Shozi H, Tonkin-Crine S, Hayward G, Butler C, Ngobese H, Drain P, Garrett N


Protocol for a randomised feasibility study of Point-Of-care HIV viral load testing to Enhance Re-suppression in South Africa: the POwER study

Dorward J,  Sookrajh Y, Ngobese H, Lessells R, Sayed F, Bulo E, Moodley P, Samsunder N, Lewis L, Tonkin-Crine S, Drain P, Hayward G, Butler C, Garrett N


Probabilistic transmission models incorporating sequencing data for healthcare-associated Clostridioides difficile outperform heuristic rules and identify strain-specific differences in transmission

Eyre D, Laager M, Walker AS, Cooper BS, Wilson DJ


Feasibility and Acceptability of Community Coronavirus Disease 2019 Testing Strategies (FACTS) in a University Setting

Hirst J, Logan M, Fanshaww TR, Mwandigha L, Wanat M, Vicary C, Perera R, Tonkin-Crine S, Lee JJ, Tracey I, Duff G, Tufano P, Besharov M, Tarassenko L, Nicholson BD, Hobbs FDR


Perspectives on COVID-19 testing policies and practices: a qualitative study with scientific advisors and NHS health care workers in England

Martindale A, Pilbeam C, Mableson H, Tonkin-Crine S, Atkinson P, Borek A, Lant S, Gobat N, Solomon T, Sheard S


Delayed antibiotic prescription by general practitioners in the UK: A stated-choice study

Morrell L, Buchanan J, Roope L, Pouwels K, Butler C, Hayhoe B, Moore M, Tonkin-Crine S, McLeod M, Robotham J, Walker S, STEP-UP team


Public preferences for delayed or immediate antibiotic prescriptions in UK primary care: A choice experiment

Morrell L, Buchanan J, Roope LSJ, Pouwels KB, Butler CC, Hayhoe B, Tonkin-Crine S, Mcleod M, Robotham JV, Holmes A, Walker AS, Wordsworth S


Improving the uptake and SusTainability of Effective interventions to promote Prudent antibiotic Use and Primary care (STEP-UP) Team, Estimating the Effect of Healthcare-Associated Infections on Excess Length of Hospital Stay Using Inverse Probability–Weighted Survival Curves

Pouwels K, Vansteelandt S, Batra R, Edgeworth J, Wordsworth S, Robotham J, Anyanwu P, Borek A, Bright N, Buchanan J, Butler C, Campbell A, Costelloe C, Hayhoe B, Holmes A, Hopkins S, Majeed A, McLeod M, Moore M, Morrell L, Pouwels K, Robotham J, Roope L, Tonkin-Crine S, Walker A, Wordsworth S, Zalevski A


Awareness of appropriate antibiotic use in primary care for influenza-like illness: evidence of improvement from UK population-based surveys

Pouwels KB, Roope LSJ, Buchanan J, Morrell L, Tonkin-Crine S, Peters M, Jones L, Castro-Sánchez E, Crook D, Peto T, Butler C, Robotham J, Walker A, Wordsworth S


Why do hospital prescribers continue antibiotics when it is safe to stop? Results of a choice experiment survey

Roope L, Buchanan J, Morrell L, Pouwels K, Sivyer K, Mowbray F, Abel L, Cross E, Yardley L, Peto T, Walker A, Llewelyn M, Wordsworth S


Reducing expectations for antibiotics in primary care: a randomised experiment to test the response to fear-based messages about antimicrobial resistance

Roope L, Tonkin-Crine S, Herd N, Michie S, Pouwels K, Castro-Sanchez E, Sallis A, Hopkins S, Robotham J, Crook D, Peto T, Peters M, Butler C, Walker A, Wordsworth S


Prescriber Commitment Posters to Increase Prudent Antibiotic Prescribing in English General Practice: A Cluster Randomized Controlled Trial

Sallis A, Bondaronek P, Sanders J, Yu L, Harris V, Vlaev I,  Sanders M, Tonkin-Crine S, Chadborn T


Developing a behavioural intervention package to identify and amend incorrect penicillin allergy records in UK general practice and subsequently change antibiotic use

Santillo M, Wanat M, Davoudianfar M, Bongard E, Savic S, Savic L, Porter C, Fielding J, Butler C, Pavitt S, Sandoe J, Tonkin-Crine S


Experiences and needs of persons living with a household member infected with SARS-CoV-2: A mixed method study

Verberk J, Anthierens S, Tonkin-Crine S, Goossens H, Kinsman J, de Hoog M, Bielicki J, Bruijning-Verhagen P, Gobat N


Transformation of primary care during the COVID-19 pandemic: experiences of healthcare professionals in eight European countries

Wanat M, Hoste M, Gobat N, Anastasaki M, Böhmer F, Chlabicz S, Colliers A, Farrell K, Karkana M-N, Kinsman J, Lionis C, Marcinowicz L, Reinhardt K, Skoglund I,  Sundvall P-D, Vellinga Akke, Verheij T, Goossens H, Butler C, van der Velden A, Anthierens S, Tonkin-Crine S


Optimising Interventions for Catheter-Associated Urinary Tract Infections (CAUTI) in Primary, Secondary and Care Home Settings

Wanat M, Logan M, Hirst J, Vicary C, Lee J, Perera R, Tracey I, Duff G, Tufano P, Fanshawe T, Mwandigha L, Nicholson B, Tonkin-Crine S, Hobbs R


Perceptions on undertaking regular asymptomatic self-testing for COVID-19 using lateral flow tests: a qualitative study of university students and staff

Wanat M, Logan M, Hirst J, Vicary C, Lee J, Perera R, Tracey I, Duff G, Tufano P, Fanshawe T, Mwandigha L, Nicholson B, Tonkin-Crine S, Hobbs R


Management of penicillin allergy in primary care: a qualitative study with patients and primary care physicians

Wanat M, Anthierens S, Butler C, Savic L, Savic S, Pavitt S, Sandoe JAT, Tonkin-Crine S


Supporting Primary Care Professionals to Stay in Work During the COVID-19 Pandemic: Views on Personal Risk and Access to Testing During the First Wave of Pandemic in Europe

Wanat M, Hoste M, Gobat N, Anastaski M, Bohmer F, Chlaicz S, Colliers A, Farrell K, Karkana M, Kinsman J, Lionis C, Marcinowicz L, Reinhardt K, Skogulnd I, Sundvall P, Vellingna A, Goossens H, Butler C, Velden AVD, Anthierens S, Tonkin-Crine S