How do we close the gaps in appropriate antibiotic use?

Increasing rates of drug-resistant infections, driven in part by the misuse and overuse of antibiotics and other antimicrobial drugs, have led to promotion of appropriate use of these drugs being recognised as a key clinical priority, both here and overseas.

In Australia, our national standards that guide the safety and quality of care in hospitals include criteria on appropriate use of antimicrobial drugs. The way these criteria were developed and have been implemented nationally is unique.

Maintaining compliance with these standards requires ongoing effort and some hospitals may need more support than others to meet their targets.

A national program that monitors antimicrobial prescribing describes variations in the quality of prescribing between metropolitan and non-metropolitan hospitals, with regional and remote hospitals reporting higher rates of guideline non-compliant prescribing. Gaps in resources between metropolitan and non-metropolitan hospitals can influence healthcare delivery.

Supporting regional and remote hospitals’ efforts to meet prescribing quality targets is a goal shared by clinicians, researchers and government.

So, how can quality and safety initiatives aimed at improving antimicrobial prescribing and use – clinically known as ‘antimicrobial stewardship’ – be encouraged outside metropolitan areas?

At the National Centre for Antimicrobial Stewardship (NCAS) at the Doherty Institute, University of Melbourne and Royal Melbourne Hospital, we are researching antimicrobial use and stewardship in regional and remote Australia.

Building workforce capacity

A review by NCAS research fellow Jaclyn Bishop and colleagues describes different models for antimicrobial stewardship programs at regional and remote hospitals, including those that run successfully without on-site local infectious diseases specialists.

It finds that enhancing workforce capacity across the disciplines is key to sustaining the day-to-day operations of these programs.

Evette Buono, the New South Wales Clinical Excellence Commission’s senior manager for knowledge, evaluation and research, says regional and remote hospitals can face challenges in sourcing the expertise needed to support quality improvement for antimicrobial use.

“Infectious diseases physicians, clinical microbiologists and specially trained pharmacists play a critical role in defining the success and credibility of an antimicrobial stewardship program, but smaller healthcare facilities are less likely to have these experts available on-site to provide hands-on support and advice.”

Models of care already used by regional hospitals to address resource constraints, like networked or ‘hub-and-spoke’ models that are based on shared resources, offer an effective alternative.

“Collaborative antimicrobial stewardship efforts across multiple facilities offer a viable model of care for regional and small metropolitan hospitals, where dedicated time and resources for antimicrobial stewardship may be scarce,” says Ms Buono.

“They also allow individuals from participating hospitals to learn from one another, building expertise and capability across the district or network, and are more likely to result in sustainable improvement.”

Strengthening clinical networks and access to off-site expertise, including through ‘tele-health’, could help, but initiatives like these need sustained resourcing.

The cultural factor

A further qualitative study examining barriers to, and enablers of, stewardship programs in regional Australia also highlights the importance of cultural factors, like a culture of independence and self-reliance among local clinicians, and familiarity with the local context.

Regional hospital staff report having a sense of pride in local institutions and a desire to deliver quality care locally. Quality improvement initiatives that include audits and feedback can build on this.

Dr David Kong, the deputy director of pharmacy at Ballarat Health Services, says that although regional hospitals generally have fewer resources and tools for extensive stewardship programs, they can strategically and intensively use audits to drive improvement.

“Undertaking audits and feeding back the results offers clinicians an opportunity to reflect on their practice,” he says.

“If the feedback and results are provided to multiple staff members or units within the same institution, these results may also facilitate competition between individuals and groups and drive improvement.”

Antimicrobial prescribing audits

Two national programs annually monitor antimicrobial usage in Australian hospitals.

The National Antimicrobial Prescribing Survey (NAPS), administered by NCAS, reports on the quality of antimicrobial prescribing in Australian hospitals and aged care homes.

The National Antimicrobial Utilisation Surveillance Program, administered by the Department of Health in South Australia, reports on population-adjusted volumes of antimicrobial consumption in Australian hospitals.

Both programs contribute to the Antimicrobial Use and Resistance in Australia project, which is supported by the Commonwealth Department of Health and coordinated by the Australian Commission on Safety and Quality in Health Care.

The NAPS program provides education and clinical assessment support to hospital staff nationally via webinar and phone consultations. Staff in regional hospitals are encouraged to use this off-site expertise to perform audits – both to disseminate and use their hospital-specific results, and to participate in national benchmarking.

A quality target identified by Australian studies is enhancing capacity for benchmarking of antimicrobial prescribing data. Regional clinicians have reported that comparing local patterns of antimicrobial use in specific clinical areas to patterns in other similar hospitals would be beneficial.

Australia’s antimicrobial utilisation surveillance programs aim to address this by facilitating comparisons between similar facilities.

Associate Professor Kirsty Buising, deputy director of NCAS, says that while participating in audits helps maintain national surveillance, they should primarily be used to facilitate local feedback and action.

“It is important that we provide data to hospitals that they can then reflect on and use to drive change locally as appropriate. We need to support the use of data for action.”

The National Centre for Antimicrobial Stewardship is hosting this year’s National Antimicrobial Resistance and Stewardship Forum, co-sponsored by Safer Care Victoria, on 1st and 2nd November at the University of Melbourne.

The forum covers clinical infectious diseases and antimicrobial stewardship, translational science, new drug development, veterinary and agricultural medicine, and government and policy responses. Workshops for scientists, microbiologists, general practitioners, veterinarians and nurses will be delivered as part of the forum.

Banner image: Shutterstock