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Background Health care professionals are in a key position to promote vaccinations. However, consulting vaccine-hesitant patients can be difficult, especially when patients bring up anti-vaccination arguments. Whereas prior research has identified essential skills for refuting anti-vaccination arguments, little is known about how to acquire these skills. Our aim was to determine if empathetic refutational interview text scenarios help health care professionals build confidence and abilities in countering anti-vaccination arguments. Methods We conducted an online randomized controlled experiment with UK and Finnish health care professionals in which we randomly assigned them to an empathetic refutational interview group ( n  = 167) or a control group ( n  = 180). Participants in the empathetic refutational interview group were presented with examples of the empathetic refutational interview approach, which encompasses the identification of attitude roots, affirmations, corrections of misconceptions, and provision of facts. Control group participants received a standard facts-based approach. We examined posttest use of empathetic refutational interview techniques and pre- and posttest perceived difficulty of refuting anti-vaccination arguments. Results Participants in the empathetic refutational interview group used more empathetic affirmations than control group participants. The empathetic refutational interview group and the control group did not differ significantly in how often they explicitly tried to identify attitude roots, correct misconceptions, and provide vaccination facts, nor in how difficult they found anti-vaccination arguments to be to refute. Conclusions Brief empathetic refutational interview text scenarios can increase health care professionals’ use of affirmations when discussing vaccines with patients. Additional materials are needed to efficiently teach refutations of attitude roots.

Background Healthcare professionals (HCPs) can play an important role in encouraging patients and their caregivers to be vaccinated. The objective of this qualitative study was to investigate HCPs’ perspectives on challenges in vaccine communication and unmet training needs in this domain. Methods Semi-structured interviews were conducted with 41 HCPs (mainly nurses and physicians) with vaccination roles (23 in England; 18 in France), gathering information on: (1) HCPs’ approach to vaccine conversations with patients; (2) Challenges of communicating about vaccines; (3) Vaccine-related training and learning resources available to HCPs, and; (4) HCPs’ training needs around vaccine communication. Results HCPs described a range of communication experiences that indicated insufficient time, information, and skills to confidently navigate difficult conversations with vaccine-hesitant patients. Communication skills were especially important to avoid conflict that could potentially damage the patient-provider relationship. Some HCPs interviewed had received communication training, but for most, this training was not specific to vaccination. Although general communication skills were transferable to vaccine conversations, most HCPs welcomed specific training and informational resources to support countering patients’ misconceptions or misinformation about vaccines. Conclusions HCPs would benefit from training tailored to address vaccine communication with patients, and this should be part of a systemic approach that also provides time and space to have effective vaccine conversations.

Recent years have shown substantial growth both in the scale and the spread of freshwater aquaculture in Thailand, raising concerns about potential widespread unsustainable use of antimicrobials. This mixed-methods study used surveys and qualitative interviews to examine conditions of freshwater aquaculture farming in central Thailand in relation to animal health, disease management and patterns of antimicrobial use. Freshwater aquaculture in this area of Thailand was largely a domestic venture operated as a source of additional household income to increase financial security. Aquaculture was often integrated with other types of farming; initial outlay was reduced by repurposing unused crops, food, or animal manure (e.g. chicken droppings and pig dung) to fertilise aquaculture ponds. Among farmers representing twenty farms who were surveyed during 2019, only six farmers representing six farms said they used antimicrobials. These included oxytetracycline, enrofloxacin, norfloxacin, ciprofloxacin and sulphonamides. Farmers doubted the benefits of using antimicrobials to treat aquatic animals; some believed antimicrobials stunted growth. The high cost of medicines and prohibitive regulations also discouraged antimicrobial use. Farmers linked disease occurrence to changes in the weather, the emergence of new diseases and variable water quality. They relied on farm management practices to maintain the health of their aquatic animals, using lime and salt to maintain and improve water quality and pH and to disinfect aquaculture pools. Farmers also reported obtaining juvenile fish and shrimp selectively from farms known to produce healthy stock. Specialised veterinary services for aquatic farming were rare, so farmers relied on their own experimentation with medicines, peer advice and recommendations of shopkeepers who sold both aquatic feed and medicines. This study unexpectedly reveals limited use of antimicrobials linked to socio-economic and ecological features of small-scale family aquaculture farms.

Objectives: Our aims were to compare faecal third-generation cephalosporin-resistant (3GC-R) Escherichia coli isolates from dogs living in a city and in a rural area ~30 km away; to compare isolates from dogs, cattle, and humans in these regions; to determine risk factors associated with 3GC-R E. coli carriage in these two cohorts of dogs. Methods: 600 dogs were included, with faecal samples processed to recover 3GC-R E. coli using 2 mg/L cefotaxime. WGS was by Illumina; risk factor analyses were multivariable linear regression using the results of an owner-completed survey. Results: 3GC-R E. coli were excreted by 20/303 rural and 31/297 urban dogs. Dog/human sharing was evident for the dominant canine 3GC-R sequence type, ST963(blaCMY-2). Cattle/dog sharing was evident for CTX-M-14 and CTX-M-32-producing E. coli from rural dogs, including sharing of plasmid pMOO-32, which is common on cattle farms in the area. Feeding raw meat was associated with carrying 3GC-R E. coli in rural dogs, but not in urban dogs, where swimming in rivers was a weak risk factor. Conclusions: Given clear zoonotic potential for resistant canine E. coli, our work suggests interventions that may reduce this threat. In rural dogs, carriage of 3GC-R E. coli, particularly CTX-M producers, was phylogenetically associated with interaction with local cattle and epidemiologically associated with feeding raw meat. In urban dogs, sources of 3GC-R E. coli appear to be more varied and include environments such as rivers. Competing Interest Statement The authors have declared no competing interest.

We report a survey (August 2017 to March 2018) and risk factor analysis of faecal carriage of antibacterial-resistant (ABR) Escherichia coli in 223 sixteen-week-old dogs in the United Kingdom. Raw feeding was associated with the presence of E. coli resistant to fluoroquinolones, tetracycline, amoxicillin, and streptomycin, but not to cefalexin or cefotaxime. Whole genome sequencing of 30 fluoroquinolone-resistant (FQ-R), 22 cefotaxime-resistant (CTX-R) and seven dual FQ-R/CTX-R E. coli isolates showed a wide range of sequence types (STs), an approximately 50:50 split of CTX-M:AmpC-mediated CTX-R, and almost exclusively mutational FQ-R dominated by ST744 and ST162. Comparisons between E. coli isolates from puppies known to be located within a 50 x 50 km region with those isolated from human urinary tract and bloodstream infections (isolated in parallel in the same region) identified a clone of ST963 E. coli carrying chromosomal blaCMY-2 in two puppies and causing two urinary tract infections and one bloodstream infection. Furthermore, an ST744 FQ-R clone was carried by one puppy and caused one urinary tract infection. Accordingly, we conclude that raw feeding is associated with carriage of ABR E. coli in dogs even at sixteen weeks of age and that bacteria carried by these dogs are shared with humans and cause serious opportunistic infections. We therefore suggest that those who feed their dogs raw meat seriously consider the potential ABR-transmission threat their pet may become as a result and deploy appropriate hygiene practices in mitigation. Competing Interest Statement The authors have declared no competing interest.

Objectives: Third-generation cephalosporin-resistant Escherichia coli from community-acquired urinary tract infections (UTI) have been increasingly reported worldwide. In this study we sought to determine and characterise the mechanisms of cefotaxime-resistance (CTX-R) employed by urinary E. coli obtained from primary care over a 12-month period, in Bristol and surrounding counties in the South West of England. Methods: Cephalexin resistant (Ceph-R) E. coli isolates were identified directly from general practice (GP) referred urine samples using disc susceptibility testing as per standard diagnostic procedures. CTX-R was determined by subsequent plating onto MIC breakpoint plates. β-Lactamase genes were detected by PCR. Whole Genome Sequencing (WGS) was performed on 225 urinary isolates and analyses were performed using the Centre for Genomic Epidemiology platform. Patient information provided by the referring GPs was reviewed. Results: During the study period, Ceph-R E. coli (n=900) were obtained directly from urines from 146 GPs. Seventy-percent (626/900) of isolates were CTX-R. WGS of 225 non-duplicate isolates identified that the most common mechanism of CTX-R was blaCTX-M carriage (185/225; 82.2%), predominantly blaCTX-M-15 (114/185; 61.6%), followed by carriage of plasmid mediated AmpCs (pAmpCs) (17/225; 7.6%), ESBL blaSHV variants (6/225; 2.7%), AmpC hyperproduction (13/225; 5.8%), or a combination of both blaCTX-M and pAmpC carriage (4/225; 1.8%). Forty-four sequence types (STs) were identified with ST131 representing 101/225 (45.0%) of sequenced isolates, within which the blaCTX-M-15-positive clade C2 was dominant (54/101; 53.5%). Ciprofloxacin-resistance (CIP-R) was observed in 128/225 (56.9%) of sequenced CTX-R isolates - predominantly associated with fluoroquinolone-resistant clones ST131 and ST1193. Conclusions: Most Ceph-R urinary E. colis were CTX-R, predominantly caused by blaCTX-M carriage. There was a clear correlation between CTX-R and CIP-R, largely attributable to the dominance of the high-risk pandemic clones, ST131 and ST1193 in this study. This localised epidemiological data provides greater resolution than regional data and can be valuable for informing treatment choices in the primary care setting.

Objectives: To characterise putative AmpC hyper-producing 3rd generation cephalosporin-resistant E. coli from dairy farms and their phylogenetic relationships as well as to identify risk factors for their presence; to assess evidence for their zoonotic transmission into the local human population Methods: Proteomics was used to explain differences in antimicrobial susceptibility. Whole genome sequencing allowed phylogenetic analysis. Multilevel, multivariable logistic regression modelling was used to identify risk factors. Results: Increased use of amoxicillin-clavulanate was associated with an increased risk of finding AmpC hyper-producers on farms. Expansion of cephalosporin resistance in AmpC hyper-producers was seen in farm isolates with marR mutations (conferring cefoperazone resistance) or when AmpC was mutated (conferring 4th generation cephalosporin and cefoperazone resistance). Phylogenetic analysis confirmed the dominance of ST88 amongst farm AmpC hyper-producers but there was no evidence for acquisition of farm isolates by members of the local human population. Conclusions: In this two-year surveillance study of 53 dairy farms, AmpC hyper-production was the cause of cefotaxime resistance in 46.2% of E. coli. There was evidence of recent farm-to-farm transmission and of adaptive mutations to expand resistance. Whilst there was no evidence of isolates entering the local human population, efforts to reduce 3rd generation cephalosporin resistance on dairy farms must address the high prevalence of AmpC hyper-producers. The finding that amoxicillin-clavulanate use was associated with increased risk of finding AmpC hyper-producers is important because this is not currently categorised as a highest-priority critically important antimicrobial and so is not currently targeted for specific usage restrictions in the UK.

To investigate whether on-farm antibacterial usage (ABU), environmental antibacterial resistant (ABR) Escherichia coli prevalence, and sampling and sample handling methodologies are associated with ABR E. coli positivity in individual faecal samples from dairy heifers. Three hundred and sixty-four heifers from 37 farms were sampled via rectal or faecal pat sampling. Samples were stored at -80°C for variable periods before microbiological analysis. Data analysis was through a multilevel, multivariable logistic regression approach. Individual rectal samples had increased odds of positivity for amoxicillin, cefalexin and tetracycline-resistant E. coli. Sample storage for 6-12 month was associated with decreased odds of finding amoxicillin and tetracycline-resistant E. coli. On-farm ABU had little influence, and environmental ABR E. coli prevalence had no significant influence on on the odds of sample-level positivity for ABR E. coli. Sampling methodology and sample handling have a greater association than on-farm factors with the detection of ABR E. coli in individual faecal samples from dairy heifers. Sampling and storage methodologies should be considered carefully at the point of designing ABR surveillance studies in livestock and their environments and, where possible, standardised between and within future studies.

Third-generation cephalosporin resistance (3GC-R) in Escherichia coli is a rising problem in human and farmed animal populations. We conducted whole genome sequencing analysis of 138 representative 3GC-R isolates previously collected from dairy farms in South West England and confirmed by PCR to carry acquired 3GC-R genes. This analysis identified blaCTX-M (131 isolates: encoding CTX-M-1, −14, −15, −32 and the novel variant, CTX-M-214), blaCMY-2 (6 isolates) and blaDHA-1 (one isolate). A highly conserved plasmid was identified in 73 isolates, representing 27 E. coli sequence types. This novel ~220 kb IncHI2 plasmid carrying blaCTX-M-32 was sequenced to closure and designated pMOO-32. It was found experimentally to be stable in cattle and human transconjugant E. coli even in the absence of selective pressure and was found by multiplex PCR to be present on 26 study farms representing a remarkable range of transmission over 1500 square kilometres. However, the plasmid was not found amongst human urinary E. coli we have recently characterised from people living in the same geographical location, collected in parallel with farm sampling. There were close relatives of two blaCTX-M plasmids circulating amongst eight human and two cattle isolates, and a closely related blaCMY-2 plasmid found in one cattle and one human isolate. However, phylogenetic evidence of recent sharing of 3GC-R strains between farms and humans in the same region was not found. Third-generation cephalosporins (3GCs) are critically important antibacterials and 3GC-resistance (3GC-R) threatens human health, particularly in the context of opportunistic pathogens such as Escherichia coli. There is some evidence for zoonotic transmission of 3GC-R E. coli through food, but little work has been done examining possible transmission (e.g. via interaction of people with the local near-farm environment). We characterised acquired 3GC-R E. coli found on dairy farms in a geographically restricted region of the United Kingdom and compared these with E. coli from people living in the same region, collected in parallel. Whilst there is strong evidence for recent farm-to-farm transmission of 3GC-R strains and plasmids – including one epidemic plasmid that has a remarkable capacity to transmit – there was no evidence that 3GC-R found on study farms had a significant impact on circulating 3GC-R E. coli strains or plasmids in the local human population.

Objectives: The objective of this study was to identify the mechanisms of cefotaxime resistance (CTX-R) in 1226 Escherichia coli from 4581 environmental samples collected on 53 dairy farms over a 2-year period in South West England and to characterise a blaCTX-M-32-producing plasmid, pMOO-32, found to be widely distributed. Methods: CTX-R isolates were identified using MIC breakpoint agar plates. β-lactamase genes of interest (GOIs) were detected by PCR. WGS was performed and analysed using the Center for Genomic Epidemiology platform. A plasmid-specific multiplex PCR was designed to indicate the presence of plasmid pMOO-32. Results: Amongst 1226 CTX-R isolates, PCR identified blaCTX-M group 1 (549 isolates), blaCTX-M group 9 (100 isolates), blaCMY (12 isolates), blaDHA (1 isolate) and no GOI (566 isolates). WGS analysis of 184 representative isolates identified blaCTX-M (131 isolates; encoding CTX-M-1, -14, -15, -32 and the novel variant, CTX-M-214), blaCMY-2 (6 isolates), blaDHA-1 (one isolate) and presumed AmpC-hyperproduction in 46 isolates that were PCR negative for GOIs. A highly conserved plasmid was identified in 73 isolates, representing 27 E. coli STs. This ~220 kb IncHI2 plasmid carrying blaCTX-M-32 was designated pMOO-32, was found to be stable in cattle and human transconjugant E. coli even in the absence of selective pressure, and was found by multiplex PCR to be present on 26/53 study farms. Conclusions: β-lactamases capable of conferring resistance to third generation cephalosporins were evident on 47/53 farms within this study. This was largely because of the widespread dissemination of an IncHI2 plasmid carrying blaCTX-M-32.