Antimicrobial stewardship in Humans

Community and general practice stream

Antibiotics are among the most common medications prescribed in general practice. Data are now being gathered regarding the volumes of particular antibiotics consumed in the community, for example by analysing data from the Pharmaceutical Benefits Scheme, but there is very little information available regarding the indications for use and the appropriateness of the antibiotic prescriptions. Work has already been done in this area, but there is more to be learnt about prescribing outside the residential aged care facilities context.

Using data already collected, an analysis will be done to look at patterns of antibiotic use and adherence to guidelines. We will explore attitudes that might influence prescribing and work with GPs and others to determine acceptable methods to deliver information.

Ultimately we intend to have gathered information about the education needs of GPs and others with regard to antibiotic prescribing and designed, trialed and evaluated interventions to identify those that are truly helpful to improve antimicrobial use in the community.

Antimicrobial stewardship (AMS) in residential aged care facilities (RACFs) stream

Recent studies  have shown a significant burden of infection and colonisation with antibiotic resistant bacteria among RACF residents and frequent inappropriate receipt of antibiotics.  The VICNISS Coordintating Centre has well established linkages and gives longstanding support to small rural hospitals that include such facilities. They have investigated surveillance methods in these setting, and described higher than international infection rates and antimicrobial use in Victorian facilities.

The researchers in this stream will to investigate the optimal way of collecting antimicrobial consumption, infection and susceptibility data in RACFs. The National Antimicrobial Prescribing Survey  (NAPS) will be pilot tested in selected RACFs. These findings will be used to identify optimal interventions to improve AMS in RACFs with further input from key stakeholders.

Ultimately this stream will identify the optimal approach to measure antimicrobial consumption and to obtain antibiotic susceptibilities for pathogens from individuals in aged care facilities, assessed the ability for the National Antimicrobial Prescribing Survey to be used broadly in the RACF setting to gather data on antimicrobial use, and identify and test interventions to optimise antimicrobial prescribing in RACFs.

Rural/ regional centres stream

Regional and rural-based hospitals face major challenges with developing and implementing AMS because of differences in patient mix, workforce and existing service delivery structures. AMS in smaller Australian hospitals is in its infancy. The institutions rely on affiliations with larger metropolitan hospitals for antimicrobial prescribing advice.

As part of the CRE, the investigators will test models for AMS in regional hospitals. The models will be adapted to suit the sites but it is intended that Telehealth links to a tertiary hospital will be used to provide regular contact for individualised post prescription review, in addition to a computerised approval system for nominated restricted medicines, structured education and regular audit and feedback. New modules of Guidance have been developed to further improve documentation and communication of advice, and these are likely to assist in Telehealth consultations. The activity of the AMS service will be measured in addition to nature of their interventions. The impact on prescribing behaviour will be measured using the National Antimicrobial Prescribing Survey tool and the acceptability of the service will be evaluated.

At the conclusion of the projects proposed, we will have identified and tested interventions to improve antimicrobial prescribing that are feasible and translatable from large hospitals to rural and regional sites with limited resources.

Tertiary Hospitals stream

Tertiary Hospitals stream

Surgical antibiotic prophylaxis was identified as the most common reason for antibiotics to be prescribed in tertiary hospitals in Australia during the National Antimicrobial Prescribing Survey (NAPS) performed in November 2013 (Unpublished data NAPS 2013). Surgical antibiotic prophylaxis is an important strategy to prevent surgical site infections however, in the 2013 NAPS survey, ~50% of surgical antibiotic prophylaxis use was inappropriate, particularly because of prolonged duration or inappropriate agent selection.

National and international surgical antibiotic prophylaxis guidelines may not reflect the local ecology of organisms associated with surgical site infections. Currently, there is a national strategy for the development of a national AMR surveillance in Australia being led by the Australian Commission on Safety and Quality in Health Care. We plan to use data coming from this program, linking data on antimicrobial resistance with antimicrobial consumption, which will improve the understanding of the local epidemiology of antimicrobial resistance and inform guideline development.

At the end of this project we expect to have empowered hospitals to critically assess the use of antibiotics for the most common surgical conditions. We will have identified and tested generalisable strategies to improve prescribing in the identified high volume and high-risk problem surgical areas.

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