HEALTH SERVICE RESEARCH CSIRO PUBLISHING

Australian Health Review, 2014, 38, 557–563 http://dx.doi.org/10.1071/AH13137

Antimicrobial stewardship activities: a survey of Queensland hospitals Minyon L. Avent1,2,12 BPharm, BSc(Hons), PharmD, BCPS, Specialist Clinical Research Pharmacist, Antimicrobial Stewardship Pharmacist

Lisa Hall3,4 BTech(BiomedSci)(Hons), PhD, Senior Research Fellow Louise Davis3 BAppSc, GDipPH, Principal Project Officer Michelle Allen3,4 BHM, Project Officer, PhD candidate Jason A. Roberts5,6 BPharm(Hons), PhD, FSHP, Professor of Medicine and Pharmacy, Pharmacist Consultant

Sean Unwin7 BPharm, GradDipClinPharm, Senior Pharmacist, Team Leader Infection Management Services

Kylie A. McIntosh8 BPharm(Hons), PhD, Progam Manager Quality Use of Medicines Karin Thursky9,10 MBBS, BSc, FRACP, MD, Clinical Director Guidance (RMH), Deputy Head Infectious Diseases

Kirsty Buising9,11 MBBS, FRACP, MD, MPH, Associate Professor, Infectious Diseases Physician David L. Paterson1,3 MBBS, FRACP, FRCPA, PhD, Professor of Medicine 1

Infection and Immunity Theme, UQ Centre for Clinical Research (UQCCR), Level 8, Building 71/918 Royal Brisbane and Women’s Hospital, Herston, Qld 4006, Australia. Email: [email protected] 2 Department of Pharmacy, Mater Health Services, South Brisbane, Qld 4101, Australia. 3 Centre for Healthcare Related Infection Surveillance and Prevention, Communicable Diseases Unit, Queensland Health, Herston, Qld 4006, Australia. Email: [email protected]; [email protected] 4 Institute of Health and Biomedical Innovation, Queensland University of Technology, 60 Musk Avenue, Kelvin Grove, Qld, 4059, Australia. Email: [email protected] 5 Burns Trauma and Critical Care Research Centre, The University of Queensland, Level 3 Ned Hanlon Building, Royal Brisbane and Women’s Hospital, Butterfield St, Herston, Qld 4029, Australia. Email: [email protected] 6 Pharmacy Department and Department of Intensive Care Medicine, Level 3 Ned Hanlon Building, Royal Brisbane and Women’s Hospital, Butterfield St, Herston, Qld 4029, Australia. 7 Princess Alexandra Hospital, Woolloongabba, Qld 4102, Australia. Email: [email protected] 8 Department of Health, 50 Lonsdale Street, Melbourne, Victoria 3000. Email: [email protected] 9 Victorian Infectious Diseases Service, Royal Melbourne Hospital at the Peter Doherty Institute for Infection and Immunity, 792 Elizabeth Street, Melbourne, Melbourne, Vic. 3000, Australia. Email: [email protected]; [email protected] 10 Infectious Diseases, MacCallum Cancer Centre, Locked Bag 5 A’Beckett Street, Melbourne, Vic. 8006, Australia. 11 Department of Infectious Diseases, Royal Melbourne Hospital, Grattan Street, Parkville, Vic. 3050, Australia. 12 Corresponding author. Email: [email protected]

Abstract Objective. In 2011, the Australian Commission on Safety and Quality in Health Care (ACSQHC) recommended that all hospitals in Australia must have an Antimicrobial Stewardship (AMS) program by 2013. Nevertheless, little is known about current AMS activities. This study aimed to determine the AMS activities currently undertaken, and to identify gaps, barriers to implementation and opportunities for improvement in Queensland hospitals.

Journal compilation
AHHA 2014

www.publish.csiro.au/journals/ahr

558

Australian Health Review

M. L. Avent et al.

Methods. The AMS activities of 26 facilities from 15 hospital and health services in Queensland were surveyed during June 2012 to address strategies for effective AMS: implementing clinical guidelines, formulary restriction, reviewing antimicrobial prescribing, auditing antimicrobial use and selective reporting of susceptibility results. Results. The response rate was 62%. Nineteen percent had an AMS team (a dedicated multidisciplinary team consisting of a medically trained staff member and a pharmacist). All facilities had access to an electronic version of Therapeutic Guidelines: Antibiotic, with a further 50% developing local guidelines for antimicrobials. One-third of facilities had additional restrictions. Eighty-eight percent had advice for restricted antimicrobials from in-house infectious disease physicians or clinical microbiologists. Antimicrobials were monitored with feedback given to prescribers at point of care by 76% of facilities. Deficiencies reported as barriers to establishing AMS programs included: pharmacy resources, financial support by hospital management, and training and education in antimicrobial use. Conclusions. Several areas for improvement were identified: reviewing antimicrobial prescribing with feedback to the prescriber, auditing, and training and education in antimicrobial use. There also appears to be a lack of resources to support AMS programs in some facilities. What is known about the topic? The ACSQHC has recommended that all hospitals implement an AMS program by 2013 as a requirement of Standard 3 (Preventing and Controlling Healthcare-Associated Infections) of the National Safety and Quality Health Service Standards. The intent of AMS is to ensure appropriate prescribing of antimicrobials as part of the broader systems within a health service organisation to prevent and manage healthcare-associated infections, and improve patient safety and quality of care. This criterion also aligns closely with Standard 4: Medication Safety. Despite this recommendation, little is known about what AMS activities are undertaken in these facilities and what additional resources would be required in order to meet these national standards. What does the paper add? This is the first survey that has been conducted of public hospital and health services in Queensland, a large decentralised state in Australia. This paper describes what AMS activities are currently being undertaken, identifies practice gaps, barriers to implementation and opportunities for improvement in Queensland hospitals. What are the implications for practitioners? Several areas for improvement such as reviewing antimicrobial prescribing with feedback to the prescriber, auditing, and training and education in antimicrobial use have been identified. In addition, there appears to be a lack of resources to support AMS programs in some facilities. Received 10 July 2013, accepted 20 August 2014, published online 5 November 2014

Introduction Research shows that up to half of antimicrobials prescribed in Australian hospitals are discordant with guidelines or microbiological results and hence are considered inappropriate.1 Inappropriate use of antimicrobials is thought to contribute to an increased risk of antibiotic-resistant pathogens.2 Patients with antibiotic-resistant infections have an increased mortality compared with patients infected with susceptible organisms.3,4 Unfortunately, new antimicrobials are not being developed at a pace that comes anywhere close to meeting the impending urgent need; therefore, the healthcare system needs to undertake efforts that save one of medicine’s most precious and long-standing resources.5 This was summarised by the World Health Day 2011 slogan ‘Combat antibiotic resistance: no action today, no cure tomorrow’. Reducing the inappropriate use of antimicrobials in hospitals has been shown to improve patient outcomes and reduce adverse consequences of antibiotic use (including antibiotic resistance, toxicity and unnecessary costs).6 The Australian Commission on Safety and Quality in Health Care (ACSQHC) has identified the implementation of an antimicrobial stewardship (AMS) program as a key initiative to address the prevention and control of healthcare-associated infections.7 The ACSQHC has recommended that all hospitals implement a program by 2013 as a requirement of Standard 3 (Preventing and Controlling Healthcare-Associated Infections), of the National Safety and Quality Health Service Standards

(NSQHS). A definition of an AMS program is one that ensures appropriate prescribing of antimicrobials, as part of the broader systems within a health service organisation to prevent and manage healthcare-associated infections and to improve patient safety and quality of care. This criterion also aligns closely with Standard 4: Medication Safety. In addition, in some facilities, implementation of an AMS program is being expected without allocation of significant additional resources. Little is currently known about what AMS activities are undertaken in facilities and what additional resources would be required in order to meet these national standards. The aim of this study was to survey Queensland hospitals to determine what AMS activities are currently being undertaken, and to identify gaps, barriers to implementation and opportunities for improvement. Methods Sample This survey was conducted in public hospital and health services (HHSs) in a large decentralised state. Queensland is Australia’s second-largest state, measuring more than 1.72 million km2 and is 25% of Australia’s land mass, which is nearly twice the size of the European Union, with a population of 4 560 060 representing 20% of Australia’s population. Queensland is Australia’s third largest state by population behind New South Wales (7 290 350) and Victoria (5 623 490).8 A survey of AMS activities was

Antimicrobial stewardship activities

undertaken in Queensland hospitals during June 2012 to identify areas requiring further support and assistance. Queensland has 17 hospital and health services. The survey was sent to 14 (of 17) Queensland Health HHSs and one large nongovernment hospital. These were selected because they have tertiary level facilities and a focus on acute care where the majority of hospital antibiotic prescribing occurs. Suitable respondents were identified from each HHS to complete the survey. If no respondent could be identified from an HHS then that HHS did not receive a questionnaire. If an HHS had multiple facilities with relevant stakeholders, all of these facilities were contacted (i.e. one HHS could contribute more than one facility). The three HHSs who did not receive any questionnaires did not have tertiary level facilities or any senior staff who could be identified as being potentially responsible for AMS (e.g. an infectious diseases physician, clinical microbiologist or senior pharmacist). These HHSs were surveyed separately as part of another project evaluating the establishment of an effective system for the implementation and evaluation of AMS programs in Australian regional and rural hospitals. Survey The survey was based on the Victorian AMS survey, which was developed by a multidisciplinary team from the quality, safety and patient experience branch of the Victorian Department of Health, together with Melbourne Health’s AMS research group in 2012. The electronic survey, with 35 multiple choice questions with an option to comment, was adapted by the Centre of Healthcare Related Infection Surveillance and Prevention (CHRISP) for the Queensland context to address five essential strategies for effective AMS as defined by the ACSQHC: implementing clinical guidelines, formulary restriction, reviewing antimicrobial prescribing, auditing antimicrobial use and selective reporting of susceptibility results. Questions covering governance structure, availability of resources, workforce capacity and other possible cultural and organisational barriers to AMS were also included. The survey was reviewed and further refined by the Antibiotic Advisory Group of CHRISP. A copy of the survey is available on request from the corresponding author. Data analysis A descriptive analysis including cross-tabulations was performed to examine the frequencies of responses and key patterns in the data. A qualitative analysis was performed on open-ended questions to determine key themes. Ethics Because the survey was determined by the Queensland Department of Health to be a quality assurance activity under the Australian National Health and Medical Research Council guidelines, ethics approval was not required. All hospital data were deidentified before reporting and involvement in the survey was voluntary. Results Response rate In total, 26 facilities from the 15 HHSs received a copy of the survey. Responses were received from 16 facilities (across nine of

Australian Health Review

559

15 HHSs), representing a response rate of 62%. Respondents included infectious diseases physicians (n = 6) and pharmacists (n = 10) who were directors, assistant directors or AMS pharmacists. Demographics Eighty-one percent (13/16) facilities have an intensive care unit (ICU) and 44% (7/16) have dedicated infectious disease beds. This represents 65% (13/ 20) of Queensland public hospitals with an ICU. There was a range of speciality services provided across the facilities, with the most common being haemodialysis 75% (12/16) and cancer care services 68% (11/16). Governance Sixty-three percent (10/16) of the facilities had a governance structure in place for their AMS stewardship program, with the following committees having accountability for the program: drug and therapeutics, medication safety, quality and risk management, infection prevention or the executive office. The remaining facilities did not have any defined governance in place. Forty-four percent (9/16) of the facilities were responsible for providing AMS services across the HHSs. These activities ranged from patient management to developing guidelines, training and reviewing data. Only 19% (3/16) of facilities had an AMS team as defined by a dedicated multidisciplinary team consisting of a medically trained staff member and a pharmacist. In addition to the infectious diseases physician, clinical microbiologist and a pharmacist, the AMS team also consisted of an infection control practitioner and member of the executive team. Only half of the facilities (8/16) had an infectious disease physician or clinical microbiologist on staff, with 25% (4/16) having access to a formally contracted infectious disease physician and a further 19% having an informal or ad hoc arrangement for infectious disease services with another facility. Guidelines All facilities had access to an electronic version of Therapeutic Guidelines: Antibiotic,9 with a further 50% developing additional local guidelines for antimicrobials. The local guidelines were mainly available on the intranet (90%). Eighty percent of the facilities review their guidelines within a 2-year period. Antimicrobial prescribing guidelines are promoted via several methods including: internal websites, orientation programs for new clinical staff, newsletters and as part of the routine clinical activities. Formulary restrictions The Queensland Department of Health has a state-wide formulary called the List of Approved Medicines. One-third of the facilities had restrictions for antimicrobials that were additional to those described in the state-wide formulary. Ninety-three percent of the facilities had a system in place for advice or approval for restricted antimicrobials, which was provided via phone by a range of clinicians and documented using a paper-based system either in the patient or medication chart, or the pharmacy (Fig. 1). None of the facilities had an electronic online approval system in place.

M. L. Avent et al.

Not applicable

Med super/ DMS

Consultant physicians (non-ID)

Off site CM

In-house CM

Off site ID clinicians

0

80

10 0

Fig. 3. Staff groups for which in-house education on best practice in antimicrobial prescribing and antimicrobial resistance is provided. Values add up to >100% because more than one category could be nominated. VMO, visiting medical officers.

prevalence studies and drug use evaluations were conducted on an as-needed basis by 31% of facilities.

70 60 50

Access to antibiograms and resistance surveillance data

40

Antibiograms estimate the proportion of antibiotic-resistant bacteria of given species in a particular local area. Despite the fact that Queensland Health has a state-wide antibiogram program, only 65% of respondents were aware of the ability to access information about antimicrobial resistance data. Facilities reported that data were accessed from several sources: microbiology laboratories; CHRISP reports; infection control departments and Pathology Queensland antibiograms.

30 20 10 Pharmacist

Quality & safety committee

Clinical microbiologist

Infectious disease physician

Drug & therapeutics committee

Infection control committee

0 AMS team

Proportion reviewing antibiotic usage rates (%)

Fig. 1. Staff groups responsible for providing the required advice or approval for prescribing restricted antimicrobials in the facilities surveyed. Values add up to >100% because more than one category could be nominated. ID, infectious diseases; DMS, Director of Medical Services; CM, clinical microbiologists.

20

None of these (no education provided)

10

30

Nursing

20

40

Pharmacy

30

50

Medical students

40

60

Junior medical staff (e.g. interns residents)

50

Senior medical staff (e.g. registrars, consultants,VMO)

60

Proportion receiving in-house education (%)

Australian Health Review

In-house ID clinicians

Proportion of advice (%)

560

Fig. 2. Person or group responsible for reviewing antibiotic usage rates. AMS, antimicrobial stewardship program.

Review antimicrobial prescribing Antimicrobials were monitored primarily by the clinicians (infectious diseases physicians, clinical microbiologists or registrars in infectious diseases or clinical microbiology), with feedback given to prescribers at point of care (e.g. clinical liaison rounds with infectious diseases physicians or clinical microbiologists in the ICU setting) in 66% of facilities. The ICU was the primary clinical area to be participating in post-prescription review, followed by specialised units such as cancer care. Auditing antimicrobial use Antimicrobial usage rates were reviewed by 76% of the facilities, mainly by the pharmacists (Fig. 2). The reports were primarily generated by CHRISP or pharmacy computer systems. Thirtyeight percent of the facilities reviewed their usage rates on a quarterly basis; however, half reported reviewing their data on an ad hoc basis. Half of the facilities noted that they would conduct an educational campaign if there was an increase in the use of a particular antibiotic, with the remaining performing an audit such as a drug use evaluation. Qualitative reviews such as point

Education In-house education on best practice in antimicrobial prescribing and resistance was provided to several health care professionals (Fig. 3). However, 31% of facilities reported that they do not provide education on AMS activities to these practitioners. Barriers Several barriers were identified by the facilities to establishing an AMS program (Table 1). Promotion of an AMS program The facilities mentioned several ways that an AMS program could be improved: implementation of an electronic approval system, formal AMS ward rounds, funding for staffing resources and better executive support. Discussion To the best of our knowledge, this is the first survey that has been conducted of public HHSs in Queensland, a large decentralised state, to describe what AMS activities are currently being undertaken, and to identify gaps, barriers to implementation and opportunities for improvement in order for hospitals to meet the NSQHS Standard 3 accreditation requirements.7 The results

Antimicrobial stewardship activities

Australian Health Review

Table 1. Ten common barriers to implementation of antimicrobial stewardship programs Barriers Inadequate pharmacy services Other competing priorities to antimicrobial stewardship activities at the hospital Insufficient financial support by hospital management Insufficient training and education in antimicrobial use provided to clinicians Lack of enforcement by hospital management Doctors reluctant to change their prescribing practices High level of transient or seconded staff Lack of leadership to promote antimicrobial stewardship at the hospital Lack of support from senior clinicians Lack of infectious diseases or microbiology services

% Respondents 77 71 59 41 30 30 29 29 24 24

Table 2. Suggestions for improvement in order to implement an antimicrobial stewardship program (AMS) 1. Improved support for AMS activities by hospital management 2. Improved recognition of positive outcomes for AMS by hospital management 3. Increased funding for AMS resources 4. Increased training and education of antimicrobial use for clinicians

are similar to the findings of an AMS program survey that was conducted in California in 2013,10 which indicated that many hospitals do have some of the key elements of an AMS program as suggested in the 2007 Infectious Diseases Society of America and the Society of Healthcare Epidemiology of America guidelines.11 It would appear that additional support is required for the majority of Queensland facilities in order to meet the NSQHS accreditation standards on AMS. This is in keeping with the AMS survey results recently reported in Victoria.12 Of the facilities surveyed, only 63% had a formal governance structure in place for an AMS program. One of the key requirements from Standard 3 of the NSQHSS is that an AMS program is in place that includes antimicrobial prescribing and management policies, plans and implementation strategies that are regularly reviewed.7 The appropriate use of antimicrobials is considered an essential part of patient safety and requires careful oversight and governance.11,13–16 It is recommended that it be incorporated into the local clinical governance.17 This is important, as the overall accountability for an antimicrobial management control program lies with the hospital administration and executive support was identified as an important strategy to promote a successful AMS program in our survey (Table 2). The responsibility for implementing and managing the program should reside with a multidisciplinary team or committee.11,17 Multidisciplinary teams are better suited to implementing the change management required for an effective AMS program.18 The purpose of AMS team is to provide feedback to individual practitioners in order to optimise treatment of infections.19 It has been suggested that as a minimum, a multidisciplinary team should include an appropriate clinician (an infectious diseases physician or clinical microbiologist, if

561

available) and a clinical pharmacist (with infectious disease training, if possible) as core team members.11,17,18 In our survey, only 19% of the facilities had an AMS team. The survey also showed that in some institutions, the AMS team also consisted of an infection control practitioner and member of the executive team. There are a range of professions that have an interest in AMS and each individual brings different perspectives and skills. A well managed team effectively incorporates multidisciplinary views and expertise.19 Where an on-site infectious diseases physician or clinical microbiologist is not available, the AMS team could be led by an interested clinician with a clinical pharmacist. In these circumstances, hospitals could negotiate appropriate external specialist advice to support the local AMS team.19 Only half of the facilities surveyed had an infectious disease physician or clinical microbiologist on staff, with 25% having a formally contracted infectious disease physician and a further 19% having an informal or ad hoc arrangement for infectious disease support with another facility. The survey showed that facilities that had an AMS team as defined by a dedicated multidisciplinary team consisting of a medically trained staff member and a pharmacist had been able to implement an AMS program and thus achieve the required NSQHS accreditation standards. However, the majority of hospitals in Queensland do not have these resources and demonstrated that they were not able to provide all the AMS activities as outlined by the ACSQHC. A competent workforce is needed to perform the necessary tasks associated with an effective AMS program. In addition, these team members should have dedicated time to perform AMS activities.19 The lack of staffing resources (infectious diseases physicians, clinical microbiologists and pharmacists) was one of the main barriers in establishing an AMS program that was reported both in our survey and in other AMS surveys that have been conducted in Australia and the USA.1,16,20 Building effective workforce capacity requires funding for dedicated AMS program staff, auditing and education campaigns, which will have an impact on program success and sustainability.12 For example, although infectious diseases physicians may work at a particular facility, additional positions may be required to perform daily stewardship rounds (Table 2). The ACSQHC recommends that the clinical workforce prescribing antimicrobials should have access to currently endorsed therapeutic guidelines on antibiotic usage.7 Prescribing guidelines for antimicrobials is an essential component of AMS programs. Several studies have shown that clinical pathways and guidelines can be effective in improving patient outcomes and the cost-effectiveness of treatment.9,21,22 Hospitals should have prescribing guidelines for the treatment and prophylaxis for common infections that are relevant to the patient population, the local antimicrobial resistance profile and the surgical procedures performed in the institution.19 Therapeutic Guidelines: Antibiotic9 is recognised as the national standard for antimicrobial prescribing in Australia.23 In our survey, all facilities had access to an electronic version of Therapeutic Guidelines: Antibiotic,9 with a further 50% developing additional local guidelines. These guidelines are promoted via several methods including internal websites, orientation programs for new clinical staff, newsletters and as part of the routine clinical activities. It is important that guidelines should have an implementation plan that is well

562

Australian Health Review

developed, executed, sustained and embedded in comprehensive programs for change to ensure an adequate uptake of guideline recommendations.24 The Queensland Department of Health has a state-wide formulary called the List of Approved Medicines, which includes antimicrobials. A formulary that includes a list of restrictive antimicrobials is an essential component of an AMS program.6,11,17 Formularies can be used to influence patterns of antimicrobial use in hospitals19 and should be appropriate to the needs of the hospital, taking into account the range of antimicrobials required, the clinical orientation of the hospital and local antimicrobial resistance.17 Formulary restrictions have decreased the amount of broad-spectrum antimicrobials prescribed, reduced adverse medication effects, decreased the development of secondary infections and thereby decreased health care costs.11,25–27 They have also been associated with changes in the local rates of some antibiotic-resistant pathogens.28,29 In our survey one-third of the facilities had restrictions for antimicrobials that were additional to those described in the state-wide formulary. An approval system that facilitates the restriction of broad-spectrum antimicrobials prescribed to patients on a clinical basis is also considered an essential component of an AMS program.6,11 The majority of facilities surveyed had a system in place for advice or approval for restricted antimicrobials which was provided via phone by a range of clinicians and documented using a paperbased system either in the patient or medication chart or in pharmacy records. None of the facilities had an electronic online approval system at the time of the survey, although this was identified as a method for promoting an AMS program. The methods for administering approval systems are varied but some form of approval must be granted by an expert prescriber under a system that is suitable for the workflow of the organisation.19 Decision support systems using online electronic approvals can provide many advantages, including reducing the work flow demands on the expert provider, which allows the provider to focus on more complex conditions;19,30,31 24-h per day access; providing consistent advice regarding approved indications;19 providing access to guidelines and providing audits of antimicrobial use.19 Antimicrobials were monitored, mainly by the clinicians (infectious diseases physicians, clinical microbiologists or registrars in infectious diseases or clinical microbiology), with feedback given to prescribers at point of care by 66% of facilities. The ICU was the primary clinical area to be reviewed, followed by specialised units such as cancer care. The Infectious Diseases Society of America has identified practice review as one of the core strategies for the foundation of an AMS program11 and has proven to be an effective strategy to influence prescribing behaviour.19 Although evidence suggest that antimicrobial prescribing review undertaken by a single health professional can be effective, a multidisciplinary team (an infectious disease physician, a clinical microbiologist and a clinical pharmacist) is more likely to have a positive impact.19 In our survey, a limited number of facilities had an AMS team to undertake reviews, primarily due to lack of staffing resources. In addition, formal stewardship rounds were identified by respondents as a means for improving their AMS program. Monitoring and analysis of antimicrobial usage data is critical to understanding antimicrobial resistance and measuring the

M. L. Avent et al.

effects of stewardship interventions, with continuous surveillance of the appropriateness of antimicrobial prescribing being the ultimate aim.19 Antimicrobial usage data were reviewed by 76% of the facilities, mainly by the pharmacists. Only 38% of the facilities reviewed their data on a quarterly basis; however, half reported reviewing their data on an ad hoc basis. Antimicrobial usage data should be interpreted together with infection control and antimicrobial resistance data.19 Despite the fact that the Queensland Department of Health has a state-wide antibiogram program, only 65% of respondents were aware of the ability to access information about antimicrobial resistance data. This highlights the need for improved communication among disciplines about AMS services and the resources that are available within the facility, and also the need for a multidisciplinary approach to AMS, which can be facilitated by the creation of an AMS team. Major reasons for inappropriate antimicrobial prescribing include a lack of knowledge about infectious diseases and antimicrobial therapy.32 In the UK, poor prescribing has been linked to the lack of an integrated scientific and clinical knowledge base, and the absence of practical prescribing instructions for undergraduates.33 Half of the facilities in our survey noted that they would conduct an educational campaign if there was an increase in use of a particular antibiotic. However, about one-third of facilities reported that they did not provide any education on AMS activities to their practitioners. Lack of training and education in antimicrobial use was identified as one of the main barriers to establishing an AMS program in our survey and in another Australian survey evaluating barriers and indicators for AMS.20 The survey was sent to suitable respondents who were identified from each HHS. We had a 62% response rate, which can be regarded as representative of AMS activities for Queensland. Although it could be argued that the reasons that the facilities that did not respond may be due to lack of resources, this survey does provide valuable insight into current AMS activities and highlights key areas for improvement when compared with the ACSQHC AMS strategies. Conclusion This survey has identified several areas for improvement such as reviewing antimicrobial prescribing with feedback to the prescriber, auditing, training and education in antimicrobial use. In addition, there appears to be a lack of dedicated resources at a local level to support an AMS program in some facilities. Our findings also support the results of surveys conducted in Victoria and in California10,12,34 and indicate that although some progress has been made, many hospitals will struggle to meet the NSQHS Standard 3 accreditation requirements, given their current resources. Competing interests David Paterson has previously been on the advisory boards for Merck, Astra Zeneca, Johnson and Johnson, Novartis and Pfizer. Acknowledgements The authors thank the Members of the Queensland Health Antibiotic Advisory Group for their invaluable assistance with the survey. JAR is funded by a

Antimicrobial stewardship activities

Australian Health Review

Career Development Fellowship from the National Health and Medical Research Council (NHMRC) of Australia (APP1048652). KB is funded by an Antimicrobial Stewardship Research Group from the NHMRC partnership grant; partners include the Victorian Infectious Diseases Service, Victorian Department of Health, Therapeutic Guidelines Limited and Epworth Hospital (Richmond, Victoria, Australia).

17

18

References 1

2

3

4

5

6

7

8

9 10

11

12

13 14

15

16

Ingram PR, Seet JM, Budgeon CA, Murray R. Point-prevalence study of inappropriate antibiotic use at a tertiary Australian hospital. Intern Med J 2012; 42: 719–21. doi:10.1111/j.1445-5994.2012.02809.x Gottlieb T, Nimmo GR. Antibiotic resistance is an emerging threat to public health: an urgent call to action at the Antimicrobial Resistance Summit 2011. Med J Aust 2011; 194: 281–3. van Hal SJ, Jensen SO, Vaska VL, Espedido BA, Paterson DL, Gosbell IB. Predictors of mortality in Staphylococcus aureus bacteremia. Clin Microbiol Rev 2012; 25: 362–86. doi:10.1128/CMR.05022-11 Infectious Diseases Society of America (IDSA). Combating antimicrobial resistance: policy recommendations to save lives. Clin Infect Dis 2011; 52(Suppl. 5): S397–428. doi:10.1093/cid/cir153 Carlet J, Collignon P, Goldmann D, Goossens H, Gyssens IC, Harbarth S, Jarlier V, Levy SB, N’Doye B, Pittet D, Richtmann R, Seto WH, van der Meer JWM, Voss A. Society’s failure to protect a precious resource: antibiotics. Lancet 2011; 378: 369–71. doi:10.1016/S0140-6736(11) 60401-7 MacDougall C, Polk RE. Antimicrobial stewardship programs in health care systems. Clin Microbiol Rev 2005; 18: 638–56. doi:10.1128/ CMR.18.4.638-656.2005 Australian Commision on Safety and Quality in Healthcare (ACSQH). National safety and quality health service standards. Sydney: ACSQH; 2011. Available at: http//www.safetyandquality.gov.au/wp-content/ uploads/2011/01/NSQHS-Standards-Sept11.pdf [verified 1 September 2014]. Office of Economic and Statistical Research, Queensland Treasury and Trade. Population growth highlights and trends. Brisbane: Queensland Government Statistician’s Office; 2012. Antibiotic Expert Group. Therapeutic guidelines: antibiotic. 14th edn. Melbourne: Therapeutic Guidelines; 2010. Trivedi KK, Rosenberg J. The state of antimicrobial stewardship programs in California. Infect Control Hosp Epidemiol 2013; 34: 379–84. doi:10.1086/669876 Dellit TH, Owens RC, McGowan JE, Gerding DN, Weinstein RA, Burke JP, Huskins WC, Paterson DL, Fishman NO, Carpenter CF, Brennan PJ, Billeter M, Hooton TM. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007; 44: 159–77. doi:10.1086/510393 James RS, McIntosh KA, Luu SB, Cotta MO, Marshall C, Thursky KA, Buising KL. Antimicrobial stewardship in Victorian hospitals: a statewide survey to identify current gaps. Med J Aust 2013; 199: 692–5. doi:10.5694/mja13.10422 Lesprit P, Brun-Buisson C. Hospital antibiotic stewardship. Curr Opin Infect Dis 2008; 21: 344–9. doi:10.1097/QCO.0b013e3283013959 Drew RH, White R, MacDougall C, Hermsen ED, Owens RC. Insights from the Society of Infectious Diseases Pharmacists on antimicrobial stewardship guidelines from the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Pharmacotherapy 2009; 29: 593–607. doi:10.1592/phco.29.5.593 Bal AM, Gould IM. Antibiotic stewardship: overcoming implementation barriers. Curr Opin Infect Dis 2011; 24: 357–62. doi:10.1097/QCO. 0b013e3283483262 Pope SD, Dellit TH, Owens RC, Hooton TM. Results of survey on implementation of Infectious Diseases Society of America and Society for Healthcare Epidemiology of America guidelines for developing an

19

20

21

22

23

24 25

26

27 28

29

30

31

32 33

34

563

institutional program to enhance antimicrobial stewardship. Infect Control Hosp Epidemiol 2009; 30: 97–8. doi:10.1086/592979 Nathwani D. Antimicrobial prescribing policy and practice in Scotland: recommendations for good antimicrobial practice in acute hospitals. J Antimicrob Chemother 2006; 57: 1189–96. doi:10.1093/jac/dkl137 Davey P, Brown E, Fenelon L, Finch R, Gould I, Hartman G, Holmes A, Ramsay C, Taylor E, Wilcox M, Wiffen P. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2005; 4: CD003543. Duguid M, Cruickshank M. Antimicrobial stewardship in Australian hospitals. Sydney: Australian Commission on Safety and Quality on Health Care; 2011. Available at: http://www.safetyandquality.gov.au/ wp-content/uploads/2011/01/Antimicrobial-stewardship-in-AustralianHospitals-2011.pdf [verified 2 September 2014]. Chen AWJ, Khumra S, Eaton V, Kong DCM. Snapshot of barriers to and indicators for antimicrobial stewardship in Australian Hospitals. J Pharm Pract Res 2011; 41: 37–41. Price J, Ekleberry A, Grover A, Melendy S, Baddam K, McMahon J, Villalba M, Johnson M, Zervos MJ. Evaluation of clinical practice guidelines on outcome of infection in patients in the surgical intensive care unit. Crit Care Med 1999; 27: 2118–24. doi:10.1097/00003246199910000-00007 Martínez R, Reyes S, Lorenzo MJ, Menendez R. Impact of guidelines on outcome: the evidence. Semin Respir Crit Care Med 2009; 30: 172–8. doi:10.1055/s-0029-1202936 Cruickskank M, Ferguson J, editors. Reducing harm to patients from health care associated infection: the role of surveillance. Sydney: Australian Commission on Safety and Quality in Health Care; 2008. Grol R, Buchan H. Clinical guidelines: what can we do to increase their use? Med J Aust 2006; 185: 301–2. White AC, Atmar RL, Wilson J, Cate TR, Stager CE, Greenberg SB. Effects of requiring prior authorization for selected antimicrobials: expenditures, susceptibilities, and clinical outcomes. Clin Infect Dis 1997; 25: 230–9. doi:10.1086/514545 Goff DA. Antimicrobial stewardship: bridging the gap between quality care and cost. Curr Opin Infect Dis 2011; 24(Suppl): S11–20. doi:10.1097/01.qco.0000393484.17894.05 Ohl CA, Luther VP. Antimicrobial stewardship for inpatient facilities. J Hosp Med 2011; 6(Suppl): S4–15. doi:10.1002/jhm.881 Landman D, Chockalingam M, Quale JM. Reduction in the incidence of methicillin-resistant Staphylococcus aureus and ceftazidime-resistant Klebsiella pneumoniae following changes in a hospital antibiotic formulary. Clin Infect Dis 1999; 28: 1062–6. doi:10.1086/514743 Walbrown MA, Aspinall SL, Bayliss NK, Stone RA, Cunningham F, Squier CL, Good CB. Evaluation of Clostridium difficile-associated diarrhea with a drug formulary change in preferred fluoroquinolones. J Manag Care Pharm 2008; 14: 34–40. Richards MJ, Robertson MB, Dartnell JG, Duarte MM, Jones NR, Kerr DA, Lim LL, Ritchie PD, Stanton GJ, Taylor SE. Impact of a web-based antimicrobial approval system on broad-spectrum cephalosporin use at a teaching hospital. Med J Aust 2003; 178: 386–90. Grayson ML, Melvani S, Kirsa SW, Cheung S, Korman AM, Garrett MK, Thomson WA. Impact of an electronic antibiotic advice and approval system on antibiotic prescribing in an Australian teaching hospital. Med J Aust 2004; 180: 455–8. Nouwen JL. Controlling antibiotic use and resistance. Clin Infect Dis 2006; 42: 776–7. doi:10.1086/500328 Marwick CA, Nathwani D. Improving antimicrobial prescribing through knowledge and skills. J Antimicrob Chemother 2007; 59: 819–20. doi:10.1093/jac/dkl546 James R, McIntosh K, Luu S, Cotta M, Marshall C, Thursky KA, Buising KL. Antimicrobial stewardship survey in Victorian hospitals: a state-wide survey to identify current gaps. Med J Aust 2013; 199: 692–5.

www.publish.csiro.au/journals/ahr