Background: Antibiotic resistance (ABR) remains a global health threat that requires urgent action. Antibiotic use is a key driver of ABR and is particularly problematic in the outpatient setting. General practitioners (GPs), the public, and pharmacists therefore play an important role in safeguarding antibiotics. In this study, we aimed to gain a better understanding of the antibiotic prescribing-use-dispensation dynamic in Malta from the perspective of GPs, pharmacists, and parents; Methods: we conducted 8 focus groups with 8 GPs, 24 pharmacists, and 18 parents between 2014 and 2016. Data were analysed using inductive and deductive content analysis; Results: Awareness on antibiotic overuse and ABR was generally high among interviewees although antibiotic use was thought to be improving. Despite this, some believed that antibiotic demand, non-compliance, and over-the-counter dispensing are still a problem. Nevertheless, interviewees believed that the public is more accepting of alternative strategies, such as delayed antibiotic prescription. Both GPs and pharmacists were enthusiastic about their roles as patient educators in raising knowledge and awareness in this context; Conclusions: While antibiotic use and misuse, and knowledge and awareness, were perceived to have improved in Malta, our study suggests that even though stakeholders indicated willingness to drive change, there is still much room for improvement. Antibiotic resistance (ABR) remains a threat to global health for which urgent action is needed, lest we end up in a post-antibiotic era . In EuroOne key driver of ABR is antibiotic use, as is evident in southern European countries where antibiotic consumption and resistance rates are among the highest in Europe ,8,9,10. Repeated Eurobarometer surveys over the past decade have suggested that Malta, a southern European country, has some of the highest antibiotic consumption rates in Europe ,22,23. ISince most antibiotic consumption in Malta occurs in the community , GPs, thIn Maltese primary care, patients are not registered with a particular GP. About two-thirds of primary care is delivered by private sector GPs  and patiThis study made part of the pre-intervention phase of a larger project, the Maltese Antibiotic Stewardship Programme in the Community (MASPIC) . We condn = 6 and n = 2, respectively). FGDs with GPs were held in the evening at a central hotel, and GPs were offered a light dinner as compensation for their time.A purposive sample of GPs registered on the Malta Medical Council’s Register and who had previously participated in individual interviews about antibiotic use and resistance, were called and invited to participate in a FGD in November 2014. Eleven GPs accepted to participate and were split into two focus groups. Three GPs, however, dropped out last minute from the 2nd focus group, therefore the final sample consisted of 8 GPs . Finally, a snowball sample of eligible parents were invited through schools and asked to recommend up to three other parents to participate. Ultimately, three FGDs were held with 18 parents   . All FGDE.A.S.-G. held FGDs with an observer/note-taker that lasted 1.5–2 h/group. Sessions were audio recorded following consent from all participants and transcribed verbatim. Data were analysed iteratively by E.A.S.-G. and H.A.S. using deductive and inductive content analysis ,35. DataEthical approval was sought from the University of Malta’s Research Ethics Committee (UREC) on two occasions. For the GPs’ FGDs, the study was deemed exempt. UREC granted ethical approval for the pharmacists’ and parents’ FGDs. Standard ethical protocols were adhered to during all FGDs. All participants were informed about the study’s purpose and that they were free to withdraw from the study or decline to answer questions without consequence. Informants were also given the opportunity to pose queries about the study, following which signed informed consent was obtained.Our findings are organized and presented across three overarching categories: (1) antibiotic use and ABR in Malta from the perspective of three stakeholder groups, (2) influence of interpersonal relationships among patients, GPs, and pharmacists on antibiotic use, and (3) solutions for action—tackling ABR in Malta.GPs, pharmacists, and parents reported that antibiotics are overused and misused in Malta, and that consequently antibiotics are losing their effectiveness. In addition, they noted that ABR has become problematic, not just in the community but also other sectors such as agriculture.“We are moving towards a time and an age where it will be very difficult to treat a normal respiratory infection because bacteria are getting very resistant.”(FGD5—pharmacists)GPs and pharmacists opined that although some people harbour misconceptions and believe antibiotics are “the holy grail”, public awareness has improved. GPs remarked that patients are more accepting of alternative strategies such as delayed antibiotic prescribing (DAP) and symptomatic therapy without antibiotics, particularly if coupled with patient education.“…there is less pressure for us to prescribe and much more acceptance by people to accept either delayed antibiotic therapy or symptomatic therapy…”(FGD1—GPs)GPs and pharmacists also explained that some people question antibiotic prescriptions or refuse them altogether, particularly parents for their children, as corroborated by interviewed parents. This was not received well by all GPs, who found it hard to persuade such patients when antibiotics are recommended. Nevertheless, both pharmacists and GPs believed that, although improving, patient demand remains a problem, and both admitted to occasionally succumbing to the pressure. According to pharmacists and GPs, some patients expect antibiotics and are disappointed when they do not receive them. Others threaten to acquire antibiotics elsewhere, which they believed may impact their reputation.“…there are those who tell you, “I came to get antibiotics”, and when you tell them they don’t need they keep insisting because the child has fever.”(FGD2—GPs)GPs and pharmacists believed that insufficient knowledge on appropriate management of cold and flu partly explains why patients pressure doctors. Patients’ expectation of instant relief was also believed to contribute to the problem, particularly if they must return to work or send their children to school. This was corroborated by parents who admitted that they sometimes do not afford taking sick leave and therefore expect antibiotics for their children.“Especially those who are either self-employed or have children who want to be sent to school early… they cannot afford to be on sick leave, so they ask for antibiotics.”(FGD1—GPs)In contrast, some parents remarked that GPs sometimes prescribe antibiotics despite only expecting a sick leave certificate.“… I go because I feel very sick and am unable to go to work and need a certificate. … A lot of times he gives me antibiotics and I challenge myself not to take them…”(FGD6—parents)Pharmacists reported that GPs’ antibiotic prescribing practices vary but that older GPs exhibit habitual prescribing behaviour, relying on experience more than guidelines, whereas younger GPs are more guideline-concordant. Consequently, some pharmacists stocked their pharmacy based on local doctors’ preferences.“…the older generation of doctors prefer certain types of antibiotics… I have a new GP in the pharmacy, who sticks to guidelines quite a lot…she does not have a habitual prescribing preference.”(FGD3—pharmacists)While parents agreed that GPs prescribe habitually, they believed that GPs overprescribe irrespective of age. Nevertheless, pharmacists and GPs believed that unnecessary antibiotic prescribing has declined, although they agreed that antibiotics are still regularly prescribed for viral infections or as an attempt to prevent secondary bacterial infections. They attributed this partly to a perceived lack of diagnostic support and local community resistance data. They believed that diagnostic uncertainty and fear stemming from prior negative experiences, further drives unnecessary and broad-spectrum antibiotic prescribing. Finally, GPs mentioned occasionally prescribing combination antibiotic therapy to cover both Gram-positive and Gram-negative bacteria, and ensure swift patient recovery, which was corroborated by pharmacists.“…when the patient needs to go to work or school quickly, I would give two antibiotics, not one… to cover Gram-negative and positive bacteria.”(FGD1—GPs)All interviewed stakeholders were generally in favour of DAP and its ability to reduce unnecessary antibiotic consumption and patient follow-up, and over-the-counter dispensing. GPs mentioned that they provide delayed antibiotic prescriptions in specific use-cases and that patients are becoming increasingly accepting of the strategy. Pharmacists reported that DAP practices varied by locality and that it seemed more popular among younger doctors and for use in children.“…it [DAP] reduced a lot of antibiotics that are used and has released a lot of pressure on us to give antibiotics over-the-counter.”(FGD3—pharmacists)Pharmacists added that clients seldom insist on dispensing delayed antibiotics prematurely without a valid reason, e.g., travel or difficulty accessing a pharmacy at night or during the weekend. Despite increasing acceptance of DAP, some pharmacists believed it is suboptimal to shift decision-making onto the patient and were therefore less in favour of it.“I don’t agree with it because they leave it at the discretion of the patient. …if the patient doesn’t need antibiotics, then don’t prescribe.”(FGD3—pharmacists)Indeed, whilst most parents stated they would unlikely consume a delayed antibiotic themselves, when it came to their children, they felt uncomfortable with the responsibility-shift. As a result, some parents preferred to have the antibiotic at hand just in case or that the GP see their child again. GPs however, believed that patients may perceive them as avaricious if they advised patients to return.“…if it is for my children … I prefer if they check them again because let’s say another two days have passed, I can’t check his throat. I don’t know if it’s better or worse… If he gives me the prescription and tells me in two days buy them, I would buy them now.”(FGD7—parents)Consequently, GPs found combining DAP with advice to call back if symptoms persist to be a good compromise, and parents expressed they would be more accepting of DAP if doctors provided better guidance. Pharmacists also believed that DAP could work if combined with patient education, and both pharmacists and GPs said they used these encounters as an educational opportunity on appropriate antibiotic use.Other potential drawbacks of DAP noted by pharmacists included the GP’s inability to confirm whether a patient took the antibiotic or not. They also believed that the customary two-day delay is insufficient as symptoms are unlikely to resolve so quickly. Pharmacists and GPs also described that GPs’ DAP methods varied, e.g., some forward-dated or marked prescriptions with a cross. Pharmacists familiar with local GPs’ practices understood these varying methods but noted that other pharmacists may not understand “the system”.“…the GP marks it with a cross. I understand her but if the patient goes to another pharmacy, I am not sure they [pharmacists] would understand.”(FGD3—pharmacists)Most pharmacists reported that they do not dispense antibiotics over-the-counter, and that patients generally accept this, especially if coupled with a rationale. Parents agreed that antibiotics are rarely dispensed over-the-counter. GPs’ views were mixed however, with some stating that it has not ceased but is on the decline, particularly since the introduction of indemnity insurance. Both pharmacists and parents admitted that in a small setting such as Malta, over-the-counter dispensing happens more frequently when people know one another.“…we’re in a small island where everyone knows one another so using the prescription as a barrier in Malta is less effective.”(FGD4—pharmacists)“...it is not the first time that I just went and bought the medicine, I know that she shouldn’t give it to me over-the-counter, but she got used to me and gives it to me.”(FGD6—parents)Both GPs and pharmacists noted that patients (including themselves) are often non-compliant, self-medicate, store antibiotics at home (likely from previously discontinued antibiotic courses), and share antibiotics with family and friends.“I have the issue of compliance myself and I know how important it is to finish antibiotics, but I never do, let alone patients.”(FGD4—pharmacists)Parents admitted to self-medicating, although rarely, but that they would not give their children antibiotics without first consulting a doctor. Similarly, while parents completed their children’s antibiotic courses, they reported sometimes stopping their own course early of their own accord, to limit antibiotic treatment or because they felt better.“…if I feel better, I stop. I know it’s wrong because I’m supposed to have the full course, but if I can avoid them, I stop them.”(FGD6—parents)Pharmacists reported that people dispose antibiotics inappropriately and are generally unaware about how to dispose of them safely. In fact, parents did not know where to dispose antibiotics safely and admitted to disposing leftover antibiotics inappropriately . Pharmacists acknowledged their role in supporting safe antibiotic disposal with some reporting that they personally dispose of clients’ leftover antibiotics at local disposal sites. Pharmacists suggested placing disposal bins in pharmacies to encourage appropriate disposal and create awareness.“They [patients] flush antibiotics down the toilet … it’s the worst thing you can do.”(FGD3—pharmacists)GPs mentioned that patients’ quick access to GPs could contribute to antibiotic overconsumption.“The advantage—and maybe a disadvantage—that we have in Malta is that the patient feels sick and makes contact with the doctor on that same day. […] We tend to see the disease very early on and most of the time, it’s difficult to decide, with the few signs that you have, what is going to happen to the patient. So, there may be a high tendency to give the antibiotic.”(FGD2—GPs)GPs also believed that patients select their GP based on the GP’s willingness to prescribe. This was corroborated by parents, although when it came to their children, parents seemed to trust GPs with judicious antibiotic prescribing more. Conversely, pharmacists explained that some people believed good doctors prescribe antibiotics whereas less competent doctors prescribe less antibiotics.“I don’t take them [children] to my GP because he immediately prescribes antibiotics”(FGD3—parent)Pharmacists viewed themselves as trusted medical professionals, from whom clients seek advice, although they reported that clients’ trust in pharmacists varied. Interestingly, parents remarked that pharmacists are better communicators than physicians.“…there are those who just take the doctor’s opinion and consider only that and the pharmacist doesn’t exist but now there are a lot who want the pharmacist’s opinion first…”(FGD3—pharmacists)Pharmacists added that patients’ trust in the doctor, a positive interaction with a pharmacist, and sufficient information about possible side effects and the importance of finishing the antibiotic course, improves compliance.The nature of the GP-pharmacist relationship varied from highly collaborative to rather detached. Pharmacists typically engaged in more open communication and collaboration with younger GPs, GPs who worked locally or at the same pharmacy.“…certain doctors, especially young doctors, they are very understanding and can relate, but especially doctors that are used to working alone, it’s like they feel insulted that I call.”(FGD5—pharmacists)Pharmacists described frequently calling GPs to discuss alternative treatment options or request clarification on prescriptions, for example. Similarly, GPs sometimes requested prescription advice from pharmacists. Some pharmacists suggested that encouraging better collaborative relationships between and among GPs and pharmacists would be beneficial.Tackling ABR was perceived to be: “…the responsibility of everyone—the patient, doctor, pharmacist, national systems…” (FGD3—pharmacists). Interviewees mentioned several potential solutions that could be implemented in this context, including educational campaigns, data access, guidelines and diagnostic support, and policy changes.GPs and pharmacists agreed that they play a critical role in educating patients on appropriate antibiotic use, drug interactions, side effects, and compliance.“...we cannot just say that antibiotics are not good for viruses. Why are they not good? What is the consequence? You cannot tell them, “I’m not going to give you antibiotics because of the resistance” because what is resistance?”(FGD5—pharmacists)GPs believed that individual patient education is more effective than public campaigns; written instructions were particularly helpful. Parents expected their GPs to provide a rationale for prescribing (or not prescribing) antibiotics but acknowledged that this did not always occur. In fact, pharmacists remarked that GPs spend insufficient time educating patients due to time constraints. They added that education is challenging when the pharmacy is full.“...you will always have a sector of the population where no matter how much time you spend trying to educate them [through public campaigns], you will not deliver the point. So, to some extent patient education must be from us—an individual approach at our clinic.”(FGD1—GPs)In addition to patient-level education, pharmacists and parents believed that ongoing, targeted nationwide campaigns delivered by experts in the field are needed. Pharmacists also suggested targeting schools, and mother and baby classes.“…to get the message through it must be a mass thing not an ‘antibiotic month’ only. You must have doctors and representatives from the health department on key radio and television channels and different populations must be targeted in different ways.”(FGD5—pharmacists)Finally, GPs were also in favour of GP education. However, they acknowledged that given their long working hours, attendance might be challenging. Pharmacists agreed and suggested that alternate strategies are needed to target GPs who cannot or are reluctant to attend education sessions.GPs believed that making local community data available through accessible national guidelines is important to tackle ABR. Although GPs reported that lack of diagnostic support limited their ability to make informed prescribing decisions, they believed that in the private sector, the added cost of diagnostic testing would not be well-accepted by patients.Pharmacists recommended introducing electronic medical records in the community nationwide to support GPs’ prescribing decisions. Without medical records, pharmacists believed that GPs are more likely to prescribe habitually rather than tailoring prescribing to the individual.“…practically all doctors don’t keep notes. So, they cannot observe patterns, like, “This patient always has a tendency of having fever that spikes quickly, so there is no need of antibiotics”. […] That, I think, is a big problem.”(FGD5—pharmacists)Similarly, pharmacists also suggested introducing e-prescriptions to track prescriptions and monitor GPs’ prescribing, which may inadvertently influence GPs’ prescribing. E-prescriptions would also eliminate illegible prescriptions that often lack sufficient information.Finally, pharmacists encouraged changing sick leave policies to allow parents to claim sick leave when their children are ill and discourage sending them to school or childcare when ill. GPs also wished for enforcement of regulations on over-the-counter antibiotic sales, to cease the practice altogether.In this study, we triangulated the views on antibiotics and ABR of three important stakeholders: GPs, pharmacists, and parents of young children. Awareness that antibiotics are being overused and that ABR is increasingly becoming problematic was generally high among interviewees although antibiotic use was thought to be improving in Malta. Despite this, some participants believed that antibiotic demand, non-compliance, and over-the-counter dispensing is still a problem. While over-the-counter dispensing has improved , Malta hDespite a perceived improvement in awareness, patients were still reported to demand antibiotics. Pharmacists and doctors also perceived that; patients expect antibiotics. Antibiotic demand is a key modifiable driver of unnecessary antibiotic use and remains a problem in various contexts ,27,37,38In our study, demand was believed to be fuelled by many factors, including the public’s subpar knowledge, the need for instant symptom relief, and stringent sick leave policies. Some parents admitted they expected antibiotics for their children when unable to take sick leave, so they could return to school sooner. At the time of this study, a sick leave certificate issued by a medical doctor was required from the first day of illness if social security benefits were to be claimed after three days of illness. Such a demand, encourages early consultation with GPs, which in turn could increase the odds of premature initiation of antibiotic treatment, as has been seen in other countries where sick leave certificates are required when absent for <7 days . RequestInterviewees noted that DAP is increasingly being accepted in this setting, although not all agreed with this strategy. The predominant reason was hesitancy to transfer decision-making responsibility onto patients. This reluctance has been shown elsewhere ,42,43,44Pharmacists also raised other issues with DAP in Malta, including lack of standardized delayed prescriptions that resulted in doctors employing varying methods, which could lead to miscommunication among all stakeholders. Pharmacists also perceived that a two-day delay was too short, particularly as many viral RTIs may need 1 to 4 weeks to resolve, depending on the complaint . ClearerGPs believed that tailored patient education is more beneficial than public efforts. Indeed, studies have shown that antibiotic campaigns intended to improve knowledge and consequently behaviour, have had mixed effects ,50. NeveInvolving community pharmacists in raising awareness through patient education could also have a positive impact . PharmacIn short, promoting and facilitating tailored patient education through both GPs but also pharmacists could help address knowledge gaps and align expectations, and improve modifiable behaviours such as demand, self-medication, and non-compliance. It could also support greater patient involvement in their own care planning. However, although imparting knowledge and raising awareness through education is an important component of behaviour change, it is not sufficient to change behaviour on its own ,55, and Both pharmacists and GPs reported that GPs occasionally asked pharmacists for prescription guidance, and some pharmacists believed that improving collaboration between GPs and pharmacists would be advantageous. Although community pharmacists’ attitudes towards their involvement in antibiotic stewardship activities and their potential impact on GPs antibiotic prescribing have seldom been explored ,57, studOver the past two years, in the midst of the COVID-19 pandemic, the general public has been flooded with information about this new virus, its management, and vaccination. People are now equipped with multitudes of information sources and the understanding that there currently is no effective treatment for this viral infection. Could this be a silver lining of these unprecedented times? Has this pandemic succeeded at increasing awareness and knowledge on the difference between viral and bacterial infections, and the understanding that antibiotics are not effective against viruses? Data from early in the pandemic show a sharp decrease in antibiotic consumption, although this is likely the result of a decline in doctor visits. As society reopens, the pandemic’s impact on health-seeking behaviour is worth investigating, particularly since visiting a physician is more likely to yield an antibiotic prescription . One couOne major drawback for RTI management in this setting was the lack of available diagnostic tools in the community. Introduction of rapid diagnostic testing in this setting has however previously been received with hesitation by GPs, primarily due to lack of human resources, infrastructure, and cost of testing . Now thaOur study was unique in that data triangulated views from three key stakeholders, giving greater in-depth understanding of GPs’, pharmacists’, and parents’ own experiences, as well as their interaction with one another. However, this study had some limitations. It was restricted to parents with tertiary-level education and so their views are limited to a particular demographic and socioeconomic group. Additionally, FGDs were held pre-pandemic and at different time points, therefore contextual changes may have impacted responses. However, as far as we are aware, between the two data collection points, there were no major policy changes that might have impacted stakeholder awareness or behaviour. Nevertheless, changes in perceptions and behaviour post-pandemic are worth exploring.Our study revealed that while antibiotic use and misuse, as well as knowledge and awareness was perceived to have improved in Malta, there is still a lot of room for improvement. Fortunately, all stakeholders indicated a willingness to be involved in various initiatives to combat ABR. Addressing ABR is complex however, and will require multifaceted, targeted initiatives that address all stakeholders . They mu


The spread of SARS-CoV-2, multidrug-resistant organisms and other healthcare-associated pathogens represents supra-regional challenges for infection prevention and control (IPC) specialists in every European country. To tackle these problems, cross-site research collaboration of IPC specialists is very important. This study assesses the extent and quality of national research collaborations of IPC departments of university hospitals located in Austria, England, France, Germany, and the Netherlands, identifies network gaps, and provides potential solutions.Joint publications of IPC heads of all university hospitals of the included countries between 1st of June 2013 until 31st of May 2020 were collected by Pubmed/Medline search. Further, two factors, the journal impact factor and the type/position of authorship, were used to calculate the Scientific Collaboration Impact (SCI) for all included sites; nationwide network analysis was performed.In five European countries, 95 sites and 125 responsible leaders for IPC who had been in charge during the study period were identified. Some countries such as Austria have only limited national research cooperations, while the Netherlands has established a gapless network. Most effective collaborating university site of each country were Lille with an SCI of 1146, Rotterdam (408), Berlin (268), Sussex (204), and Vienna/Innsbruck (18).The present study indicates major differences and room for improvement in IPC research collaborations within each country and underlines the potential and importance of collaborating in IPC.The online version contains supplementary material available at 10.1186/s13756-022-01176-x. In every European country, infection prevention and control (IPC) specialists must tackle multiple challenges to maintain high standards for patient safety. The spread of SARS-CoV-2, multidrug-resistant organisms (MDROs), healthcare associated pathogens and the fight against healthcare-acquired infections requires evidence-based approaches. Furthermore, frequent patient transfers due to interdisciplinary need of treatment facilitate a possible spread of healthcare-associated pathogens and MDROs across wards, hospitals, regions and even borders –4. HospiBuilding collaborations and extending networks across institutions, countries and nations is a course of action increasingly used to generate new knowledge , 6. ThesHowever, the extent of scientific collaboration may vary from one country to another or between regions, with the influence of cross-site research collaborations in IPC on the output and quality of research not assessed yet. The aim of the present study was to analyse and compare the extent and quality of national research collaborations of IPC departments of all university hospitals located in Austria, England, France, Germany, and the Netherlands, as well as identifying network gaps and provide potential solutions.We performed a comparative study to evaluate the extent and quality of scientific collaborations between IPC heads over time in all national university hospitals in Austria, England, France, Germany, and the Netherlands. The study period was defined as 1st of June 2013 until 31st of May 2020. We measured all scientific publications of IPC heads (pub) and separately joint publications (jnt-pub) with other IPC heads. Additionally, data on scientific collaborations, data on the individual research performance i.e. H-indexes of the heads was also collected.To investigate research collaboration regardless of country size, the goal was to include at least two small (Austria and the Netherlands) and two large countries (France and Germany) in Europe that are highly active in IPC research. In addition, England was included because it offers a unique and rather united health care system.University hospitals of each country were included. In case of major cities with multiple university hospitals belonging to the same university (e.g. Paris) only the overall IPC head was included. Multiple heads were only included if there were multiple university hospitals belonging to different universities present (e.g. Amsterdam).Leaders of each IPC department of all university hospitals (sites) were evaluated by desktop-based research and/or by email/telephone requests to the institution.Individuals were included if they were holding the academic head position of the IPC department or service at some point during the study period. If the IPC head at a site had changed during the study period, then all IPC heads of this site were included in the analysis. Sites were excluded if the IPC head identified had not published any Pubmed/Medline-indexed research during the study period.The publications of each identified author were evaluated by Pubmed/Medline search using the last name and several variations of the first name . Additionally, each detected publication was screened manually to verify the authorship. The filter tool was set to the period each author was holding the position of leader of IPC at the university hospital during the study period. Pubmed was chosen as a data search tool due to its status as a broad used reference source in the biomedical-, life-, and health science community, and its free access to a broad population.Furthermore, the Hirsch-Index (H-Index) for all authors was identified at the same date, 21st of June 2021, using the Web of Science database. To calculate the mean H-Index for a site, the H-Index of each author from the site was multiplied by the years of holding the leader position (together maximum 7 years) and divided by 7.To measure the grade of professional networks of scientists, the well-documented record of joint authorship provides a helpful evaluation tool . EvaluatA joint authorship was defined as the joint authorship of peer reviewed research papers  by a minimum of two authors of the same country. Only outputs published during the time both authors were leads of IPC were included. Documents were excluded if authors were not listed individually but as part of a consortium or research group. In addition, books and conference papers were excluded.To evaluate the impact of the scientific collaboration and the contribution of a site, the joint publications were weighed by two more factors, the journal impact factor and the type of authorship position. Therefore, each publication was multiplied by factor 5 for a first or last authorship, resulting in authorship points (APs) for the publications.The APs were then multiplied by the most recent 5-year impact factor (IF) of the journal. To avoid multiplications by zero where a journal may have not received an IF yet, one point was added to the IF (IF + 1) before the multiplication. Impact factor search was conducted via the Clarivate Journal Citation Report and Scimago.Finally, the sum of all weighted joint publications of a site was calculated and named the Scientific Collaboration Impact (SCI) of the site.SCI (X) = ∑ AP x (IF + 1).I.e.: To visualize the nationwide collaboration networks, Cytoscape open-source software 3.8.2. was used.Nodes indicate each site of a country. The intensity of the colour of a node defines the strength of the total SCI. The weighted collaborations between one site and a collaborating site of each year are indicated as width of edges in a different greyscale colour mapping.p-values were calculated. The significance threshold was set at 0.001. R-values: > 0.7 = strong correlation; 0.5–0.7 = moderate correlation, > 0.4 = weak or no correlation; p < 0.05 = significant, p-value threshold: 0.001.To evaluate correlations between (mean) joint publications and (mean) publications, Pearson correlations coefficient (r) and In five European countries, 95 sites were identified , followed by the Netherlands (186), and Germany (65), while again England (21) or Austria (6) had lower scores. It needs to be considered, however, that high SCI scores indicate high impact of collaboration, regardless in which way that has been achieved, e.g. multiple collaborating sites, repeating collaboration between two sites, or publications in high impact journals. Even though Germany had a higher network extent (76% vs. 62%), the mean SCI scores (65 vs. 201) and total numbers of collaborations were lower than in France (61 vs. 78) due to publications in journals with minor impact. Austria had only one collaboration between two sites during the study period. This led to a comparable percentage of collaborating sites (33%) to England (29%) but to a lower mean SCI score (6 vs. 21). Furthermore, also the mean number of joint publications per site was highest in the Netherlands (2.50), followed by France (1.92), and Germany (1.26).The mean SCI per site varied between 6 (Austria) with only one published scientific collaboration, and 201 (France) with 50 joint publications. Taking a closer look within the countries, with a score of 18 each, Innsbruck and Vienna equally had the highest SCI of Austria. Sussex , Lille , Berlin , and Rotterdam  were identified as sites with the highest SCI of their countries. Determinations of mean H-Indexes resulted in a range between 16 (England) up to 35 (the Netherlands). SCI, publications without cross-site collaboration and joint publications per site of each country are prented in Fig. To evaluate the scientific collaborations in IPC over time, the national networks were visualized in Fig. In the present study, research collaboration networks of IPC departments at all university hospitals located in Austria, England, France, Germany, and the Netherlands were analysed and compared for a period of seven years. All five countries and their 95 included university hospitals were evaluated for persons in charge for IPC during the study period. Network diagrams of 121 joint publications, weighted by type of authorship and impact, were used to visualize differences in scientific collaboration between the sites and counties.The network visualization delivered some remarkable results. While some countries, such as Austria, have only very limited national research cooperations, others, such as the Netherlands, have established a gapless network including all university hospitals in the country. Of interest is also the comparison between capitals. While Berlin is the most connected site in Germany, Paris and Amsterdam are not the best nationally connected of their country, Vienna has only one joint published project, and London did not contribute to national joint publications.There is, however, a peculiarity affecting the data on Paris. In Paris many local university hospitals do have their own IPC team. For example, in the case of the Public Hospitals Assistance of Paris, thirty-nine hospitals stand under the same administrative umbrella, having their own IPC team, all coordinated centrally. Some heads of IPC teams in the 39 sites hold professorships and are scientifically speaking very active. However, they were not included in our study since they did not meet our inclusion criteria. The national level connectedness of Paris is therefore underestimated in our study.The comparison of national networks could be affected by the different health care systems, research funding schemes, sizes, and number of hospitals. Therefore, to compare output and impact of national networks within the countries, extension of networks and numbers of joint publications are discussed for every country in the following.Austria showed a rather high rate of mean publications (n = 45) and mean H-Indexes (23) per site, indicating strong internal research activities, but only one national collaboration. The research was driven by a single strong site, Innsbruck, with 181 publications and a H-Index of 62. Other sites did not publish many publications, ranging from 41 to one, or H-Indexes (26 to 2), suggesting a lower focus on IPC research at university level. Compared to the other four investigated countries, the national IPC university network in Austria has room to grow with only one single collaboration between Vienna and Innsbruck. The low proportion of joint publications to the total amount of publications (1 vs. 269) at all sites offers broad room for improvement. It would be plausible to assume that sites with strong research activities enhance collaborations. However, the national collaboration level did not show any relation to the overall research activity in Innsbruck and Vienna. Even though heads of departments and IPC leaders might be connected in a professional way by and to national IPC and hygiene societies, the national research collaboration of university hospitals in IPC appeared to be relatively weak compared to the other evaluated countries. Since the specialization in IPC is done together with Clinical Microbiology, there could be less sense of community and difficulties in networking due to a larger number of graduates. There is broad national scientific collaboration in the development of IPC guidelines through the Austrian Society for Hygiene, Microbiology and Preventive Medicine (ÖGHMP). However, obviously does this not lead to extensive national research cooperations. Also, the Austrian Society specifically for Hospital Hygiene (ÖGKH) focuses mainly on professional policy issues and is hardly involved in scientific research. Still, IPC experts and leaders may already be united in both societies, so they could function as advocates for more national and cross-site collaboration in IPC research.The Netherlands showed highly active research with high-impact research outputs, as indicated by the high mean number mean publications (n = 77) and mean H-Indexes (35) per site. Additionally, the mean number of national collaborations per site was high (n = 5.25), and each site was involved in an average of 2.5 joint publications. Although, when comparing the proportion of mean joint publications to mean overall publications (0.03), the Netherlands could also increase the proportion of national co-authored publications. Especially Amsterdam VU, Groningen and Utrecht with the lowest joint publications compared to the total number of publications  in the country. Still, the Netherlands represent the strongest national scientific IPC network in Europe producing high impact publications in plenty of collaborations. A possible explanation for this may be that in the Netherlands, there is a widespread awareness of the strengths of collaborative network approaches in infection control, as reflected by frequent activities in European study groups and cross-border programs. This network approach is also mentioned as an important strategy to combat the spread of highly resistant microorganisms on a regional level in a vision document from the Dutch Society of Medical Microbiology (NVMM). On top of that, nationwide networking begins early during IPC specialization, because nationwide joint courses are a mandatory part of the well-structured IPC specialization program for physicians.England had rather low IPC research activities, measured by mean publication rate (19) and mean H-Index per site (16). The rate of mean joint publications (0.33) was low in proportion to the mean rate of publications (19). Southampton, however, showed a one-to-one proportion of joint publications to publications in combination with a high SCI (264), indicating a strong focus on national collaborating work compared to the other sites in England. However, it is difficult to draw conclusions about the IPC community and their research in England. Due to a different system in terms of the status and even definition of university hospital  and the relations between the healthcare and educational system, it is rather complicated to compare England with the other four countries, with some existing collaborations potentially missed, and difficulty to assign IPC heads to certain hospitals with the ease demonstrated in other countries, as some organisations have ceased to exit following mergers with others or due to national reorganisations.A high mean SCI per site of France (201) indicates a strong national IPC network. Further, France offered the highest number of national co-authored publications (n = 50) compared to the other four investigated countries. However, a low mean H-Index (20) and low mean numbers of publications (n = 34) might imply less research activity in IPC overall. Nevertheless, the high mean SCI per site suggests that the impact of national collaborations is rather high. Hence, the network focusses on the production of few high-impact factor publications instead of low-impact mass production. The French sites Bordeaux, Dijon, Lyon, Paris, and Tours have a strong focus on collaborating work, reading their SCI and proportions of joint publications to total publications in seven years. Amongst all five countries, France holds a highly active national network in IPC.Germany presents an overall moderate research activity with a mean H-Index scores per site (22) and mean publications per site (n = 26). Further, a mean of 1.79 collaborations and 1.26 joint publications per site in seven years could be an incentive to improve and activate national collaborating work. However, the portion of joint publications among the overall publications was high, suggesting that when IPC research is conducted, it typically does involve national collaboration. Although Aachen, Berlin and Heidelberg did have high SCI scores  and a high amount of publications , however the joint publication rate  was low, indicating few activities in national networking, but with good impact. Hamburg, Cologne and Munich TU showed the best collaborating indices, when combining SCI and the quotient . Of interest is that the Germany network in the mean has an extent of 76%, however, the visualization of the network shows that in Germany are basically three independent networks in place. These three networks have almost none or no connections to the other networks and are in this very different to the other European networks. Hence, connecting these independent networks with each other might increase the effect on research significantly and perhaps could result in scores comparable to France or the Netherlands, since lots of potential might be unused at the moment.Interestingly, in every country at least one university hospital exist that does not have many national collaborations, but one of the highest number of overall publications in the country, i.e. the university hospitals of Innsbruck, Marseille, Utrecht, Greifswald, and Imperial College London see Fig. . Hence, To improve IPC research with multicentre collaborations has already been discussed in the past . HoweverSuccessful cross-site research collaborations might also imply a benefit for the individual research reputation of the involved sites. One of our hypotheses was that a high number of collaborations would also result in high quantity of citations of the sites researchers. However, this could not be verified, as there was no correlation between the number of collaborations per site and the mean H-Index of the site. As a limitation, the H-Index indicates the entire carrier of scientist, and cannot easily be adjusted to only a period of time. Therefore, it is possible that the H-Index resulted from research before an author was affiliated as head of IPC with a site.Still, the national research collaborations that resulted in high impact joint publications contribute to the H-Index of a site. Further, sites with more collaborating publications were positively correlated with higher total numbers of publications, indicating ambitious researches for these sites.The present study bears some limitations. Due to availability of data, only the leaders of IPC departments were included for joint publication search, that could have led to missing collaborations if the IPC lead was not listed as author of a research article. However, to minimize data gaps and biases, and to equalize chances for all countries and sites, the search was focused on IPC heads as representatives of each site. Additionally, the diversity in healthcare-systems of the investigated countries could have influenced the identification of university hospitals and IPC leads.Nevertheless, this study indicates differences and room for improvement in IPC research collaborations within each country and underlines the potential and importance of collaborating in IPC.To promote cross-site collaboration in IPC research we would suggest the following: Firstly, we propose the identification of hubs and gaps in the network and the creation of benchmarks in terms of targets to improve connectiveness. For example, the target to connect non-associated facilities with at least one project next year, and subsequently the appointment of persons in charge in the concerned facilities. The results of our study could be used as blue print.. In particular, sites with a strong research activity but few collaborations such as the university hospitals of Innsbruck, Marseille, Utrecht, Greifswald, and Imperial College London might easily raise their collaboration rate. Secondly, networking could be improved as a soft-skill development training. For instance, starting national networking at an early stage, e.g. during the IPC specialization, by organizing national exchange events and meetings for young doctors in training might act as seed event which could blossom in long-term scientific exchange. This could be supported by national grants for young doctors and PhDs issued by the national scientific societies. These grants could define as a condition that a minimum of 2 young researchers from different facilities need to be involved. Lastly, we must create awareness of the importance and advantages of national and international cohesion in this essential topic and support cooperative tendencies rather than competitive tendencies.The network visualizations presented here might provide insights and connecting points for national researchers to establish new collaborations, as cross-site, comprehensive IPC research is desirable for every country in the fight against the spread of infectious pathogens.Additional file 1. Table S1: Included university hospitals, Scientific Collaboration Impact, publications, and H-Index.


When the energy was elevated between 0.08 MeV and 1.408 MeV, the highest values were attained for concrete A, with values ranging between 0.451 cm−1 and 0.179 cm−1. The lowest half-value layer (Δ0.5) values were achieved for concrete C, where the Δ0.5 values varied between 1.53 cm and 3.86 cm between 0.08 MeV and 1.408 MeV. The highest Δ0.5 values were achieved for concrete A, where the Δ0.5 varied between 1.77 cm and 4.67 cm between 0.08 MeV and 1.408 MeV. According to this investigation, concrete A has the highest promise in radiation shielding purposes because it has the most desirable properties of the concretes studied.We aimed, in this investigation, to prepare novel concretes which can be used in gamma-ray shielding applications. The experimental approach was performed using a NaI (Tl) detector to measure the concrete’s shielding features for different energies, ranging from 0.081 MeV to 1.408 MeV. The density of the fabricated concretes decreased with increasing W/C ratio, where the density decreased by 2.680 g/cm Gamma-ray is electromagnetic radiation that is frequently utilized in diverse fields, including nuclear energy, nuclear medicine, agriculture, industry, dental centers, and many other fields. It is known that gamma photons are massless and chargeless, travel at the speed of light, and have high penetration ability; therefore, the shielding of the gamma ray is very difficult. Thus, the development of novel materials, with sufficient attenuation ability, is an important challenge facing workers in the field of radiation shielding materials. When nuclear engineers plan to fabricate shielding materials, many factors must be taken into account, in order to obtain materials with interesting attenuation performance. These factors include the density, the thickness of the medium type, and energy of the radiation ,3,4,5,6.3 and it is a good choice as a protective material in some applications. It is also used for the storage of high-level nuclear waste. The low cost and simple preparation method are the main reasons that encourage civil and nuclear engineers to focus on developing certain kinds of concrete with different aggregates as shielding materials against low and medium γ-ray energy (Eγ). Moreover, some types of concrete are composed of a mixture of light and heavy nuclei, so can be applied not only to shield the γ-photons, but also to shield the neutrons [Heavyweight concrete is concrete that possesses a density higher than 2.6 g/cmneutrons ,8.Several previous works have shown that when the density of the medium is increased, the attenuation performance of this medium is improved. One common way to increase the density is by adding heavy materials. Accordingly, a few years ago, researchers were interested in enhancing the attenuation performance of concrete by adding heavy aggregates, such as hematite , magnetiTamayo et al. prepared a high-density concrete, utilizing siderurgical aggregates, and experimentally studied the radiation attenuation factors for the prepared concretes. They also investigated the impact of the W/C ratio on the attenuation parameters . Abo-El-Enein et al. prepared ordinary Portland cement pastes with hematite nanoparticles and ZnO nanoparticles and studied the influence of these nanoparticles on the thermal resistance and mechanical properties features. According to their results, the addition of 0.05% ZnO nanoparticles had a negative impact on the radiation protection efficiency of the prepared samples .Roslan et al. fabricated high-density concretes with ferro-boron aggregates and studied their radiation attenuation ability. They found that the density was enhanced with the addition of ferro-boron, and that the concrete mixed with ferro-boron has superior shielding properties to the control specimens. They concluded that the addition of ferro-boron causes an enhancement in photon attenuation capabilities .Liu et al. fabricated barite concretes using waste materials and studied the lead leaching, drying shrinkage, and mechanical properties. They used MCNP simulations to examine the gamma-ray shielding features. They demonstrated a reduction in the photon shielding features with the addition of funnel glass .In this investigation, we aim to fabricate new concretes that may be utilized in the radiation shielding field, using a NaI (Tl) detector to predict the concretes’ attenuation properties between 0.081 and 1.408 MeV. 3 (pV) to the bulk volume (bV). The pV was obtained by comparing the difference in mass between the saturated and dry specimen. The porosity was determined according to Equation (1), with resulting values listed in The concretes were prepared as a mixture of Portland cement, granite (coarse aggregate), and red sand (fine aggregate) with ratios of 1:3:2 by volume. Firstly, the ratio of each component used in the preparation was determined using an electric balance with an accuracy of ±0.01 g. After that, the weighted ratios of granite, cement, and sand were manually mixed well for 15 min. Thereafter, the chosen water ratio was added to the mixture and the effect of water/cement (W/C) on the porosity, density, and radiation shielding parameters was studied. The W/C ratios selected in the study were 0.4, 0.6, and 0.8. The mixture was then molded in the steel cubic molds with dimensions of 7 cm (length) × 7 cm (width) × various thicknesses and the prepared concretes, with different thicknesses, were left to dry for 15 days. Finally, the density was determined using the MH-300A densimeter, with an accuracy of 0.001 g/cm3 . The matµ) describes the capacity of the shielding material to tolerate crossing photons, and it is the most important protecting feature  detector. The detector recorded incident and transmission intensities, both with and without the constructed concrete (I and oI). The produced concrete samples were all the same thickness. We plotted the relation between (I/oI) and the sample thickness, and from the slope of the obtained curve determined the µ value for each concrete sample [The linear attenuation coefficient  to transmitted (I)) and sample thickness . It is the most important operator for predicting a shield’s propensity to attenuate γ-radiation. The calculation for the linear attenuation coefficient (µ) is shown in Equation (2) [The experimental tion (2) .(2)μ(cm0.5) can be calculated from µ values, namely [The half-value layer Δ0.5TF, %) is a parameter that can be used to calculate the rate of γ- ray passing through a known thickness of concrete and is shown in Equation (4) [The transmission factor (tion (4) . MoreovepV, bV, Φ, and the density of the fabricated concretes. Raising the W/C ratio from 0.4 to 0.8 increased the pV values from 6.68 to 8.83% and was accompanied by a slight increase in bV values from 53.75 to 54.90%. The increase in pore volume combined with the increase in the bulk volume caused an increase in the porosity of the concrete from 12.4 to 16.1%, as shown in 3), where the ρ values decreased slightly, from 2.68 to 2.56 g/cm3.The W/C ratio has a great impact on the structural properties γ) from the applied radiation sources affected the µ values. µ diminished with the elevation of the incoming energy from the γ-photons. At low energies, the photoelectric effect (PE) is the reason for high µ values, and one must remember that the PE cross-section is inversely proportional with the Eγ (σPE α Eγ−3.5) [γ to above 0.1 MeV, the Compton scattering effects (CS) began to change the behavior of the µ values, which fell progressively in line with the rising Eγ values. These changes in the µ behavior were attributed to the proportionality of Cs cross-section with the incoming Eγ (σcom α E−1). As clarified in µ values among the fabricated concretes, followed by concretes B and C. The µ values for all concretes decreased when the energy was increased from 0.081 to 1.408 MeV. The highest µ values were achieved for concrete A, where the µ varied between 0.451 cm−1 and 0.179 cm−1 when the energy was raised between 0.08 and 1.408 MeV. The lowest µ values were achieved for concrete C, where the µ values diminished to between 0.390 cm−1 and 0.148 cm−1 when the applied Eγ was raised between 0.08 and 1.408 MeV, respectively. There were some small anomalies observed in the µ values at some discrete gamma-ray energies; thus, the measurements were repeated four times and the uncertainty in measurements was calculated. Radiation shielding factors were measured experimentally, to determine the concretes’ ability to resist the γ-photons.  Eγ−3.5) ,24,25. Wµ values. µ values, in the Eγ, range from 0.081 to 1.408 MeV, as a result of raising the concretes’ ρ values. µ values were enhanced, from 0.215 to 0.270 cm−1, raising the concretes ρ values from 2.56 to 2.68 g/cm3, respectively, at Eγ of 0.344 MeV. The same trend was observed for other Eγ values, where the µ value was raised from 0.157 to 0.186 cm−1 at Eγ of 1.332 MeV. The present study showed that increasing the W/C ratio in fabricated concrete caused a notable reduction in the concretes’ ρ, which consequently caused a negative effect on the µ values and other shielding properties. The ρ values were reduced, ranging between 2.68, and 2.564 g/cm3 for concretes A, B, and C, as the W/C ratio was increased to values of 0.4, 0.6, and 0.8. This decrease in the ρ values, with increases in the W/C ratio, may be attributed to the hypothesis that “raising the W/C ratio leads to the formation of air bubbles inside the concrete layers”. These air bubbles were destroyed and formed pore holes after drying the fabricated concretes. Raising the W/C ratio was usually associated with an increase in the number of pore holes created inside the fabricated container, which had a negative effect on gamma-ray shielding.The fabricated concretes’ Φ and ρ were strongly affected by the concretes’ measured µ values for the fabricated concretes. At Eγ of 0.081 MeV, the measured µ changed from 0.45 cm−1 to 0.39 cm−1, due to the increase in the Φ values, from 12.71 to 16.02%, respectively. Similarly, at Eγ of 0.662 MeV, the µ values decreased from 0.237 to 0.197 cm−1 with the rise in Φ values. This decrease in the µ ay be attributed to the increase in the pore volume inside the concrete.In order to confirm this hypothesis, the Φ values were studied see b. Figureµ values of the fabricated concrete and those for the other previously reported concretes was performed . For all fabricated samples, the TF values were highly increased when raising the incoming Eγ. This increase was attributed to the predominant CS interaction inside the concrete samples, where CS interaction allowed the photons to accumulate inside the sample, throughout the experiment, consuming only a small part of the incoming Eγ during the interaction. The TF values for concrete A (for example), increased from 40% to 70 % when Eγ varied between 0.081 and 1.408 MeV  and from 55 to 25% (for concrete C), when Eγ varied between 0.081 MeV and 1.408 MeV.The calculated RPE values for the fabricated concrete are also shown in 0.5 can describe the fabricated concretes’ ability to reduce the number of transmitted γ- photons. As shown in 0.5 values fluctuated with the rise in incoming Eγ, allowing the required thickness of the concrete composition for radiation shielding to be identified. Conversely, the Δ0.5 of the fabricated concretes was increased by raising the Eγ and the W/C ratio. The lowest Δ0.5 values were achieved for concrete A, where the Δ0.5 values varied between 1.53 cm and 3.86 cm when the Eγ was raised from 0.08 to 1.408 MeV. The increase in the Δ0.5 for the fabricated concrete samples can be attributed to the same reasons discussed in the µ section.The Δ3, when the W/C ratio was raised from 0.4 to 0.8. Moreover, the porosity calculation showed that the Φ values inside the fabricated concrete increased when the W/C ratio was raised. Furthermore, an experimental approach was performed in order to assess the radiation protection features of the fabricated concretes with the Eγ range extended from 0.081 to 1.408 MeV. The highest µ values observed for concrete A decreased from 0.451 cm−1 to 0.180 cm−1 at values of 0.081 and 1.408 MeV, respectively. The examinations were confirmed using the computed other shielding parameters, such as TF, RPE, and Δ0.5. The TF of the fabricated concretes was observed to be significantly diminished with the raising of the incoming Eγ. Conversely, the RPE values were reduced due to the increase in the incoming Eγ. As can be seen, the fabricated concrete A had the highest values of TF  and RPE (60% at 0.081 MeV). Based on the measurements of RPE and Δ0.5, it was established that fabricated concretes are preferred in many radiation shielding applications.The present work studied the W/C ratio effect on the radiation shielding properties of concretes. Therefore, three samples of concrete were fabricated, using a mixture of Portland cement, red sand, and granite aggregates, with ratios of 1:2:3. The W/C ratios were adjusted to be 0.4, 0.6, and 0.8. The measurements for the fabricated concretes’ ρ values showed that the ρ values slightly decreased from 2.68 to 2.56 g/cm