Milestones, challenges in antimicrobial stewardship

ANTIMICROBIAL-resistant pathogens, such as carbapenem-resistant Enterobacteriaceae and methicillin-resistant Staphylococcus aureus, pose a serious threat to modern medicine.

While antimicrobial resistance (AMR) was recognised decades ago — indeed, soon after the development of the first antibiotics — the problem has increased rapidly in recent years, and there are fears that it may be beginning to exceed our ability to control the situation.

Though doctors and researchers have been reflecting on therapeutic interventions to come to grips with the problem, we are still in the early stages of setting up system-wide countervailing strategies and policies. Indeed, only recently have system-wide efforts started gaining momentum.

In September 2016, the  General Assembly of the United Nations gathered to discuss AMR. This was only the fourth time in history that a health issue had prompted such action, demonstrating the importance of the problem globally. The result was a draft resolution that called for action to ensure the appropriate use of antimicrobials across animal and human health.

In November 2016, Australia released an implementation plan to accompany its 2015 National Antimicrobial Resistance Strategy and outline areas requiring attention.

A key strategy involves the implementation of antimicrobial stewardship (AMS), that is, activities designed to optimise the use of antimicrobial drugs. The objective is to ensure that people who need these drugs receive them, but also to avoid unnecessary use, minimise toxicity of therapy, and importantly, minimise the impact of the selection of pathogens with antimicrobial resistance.

A key objective of Australia’s national research agenda and health policy should be to develop effective AMS systems in all the sectors in which antimicrobials are primarily used. This includes hospitals, community care settings (including general practice and aged care settings), veterinary medicine and agriculture. This takes into account the concept of One Health, which posits that human health, animal health and the environment are all interconnected and that antimicrobial use in one sector will influence another.

Australian stewardship – advancements in the field

At the outset, it should be noted that Australia has been fairly advanced in terms of its thinking on AMS, at least with respect to hospitals and the tertiary care sector, and is internationally recognised as a leader in the field.

Australia is one of a handful of countries to have developed comprehensive national guidelines for antibiotic prescribing in hospitals and general practice. The Australian Commission on Safety and Quality in Health Care (ACSQHC) has introduced strong clinical standards that emphasise medication safety and infection prevention, and since 2013 has required all hospitals to take action with regard to AMS.

The ACSQHC is working on updating a publication, Antimicrobial stewardship in Australian hospitals, which was released in 2011 and helped to guide activity in the sector. The new book, which is due for publication in 2017, will expand on areas such as community care, aged care, paediatrics, veterinary and livestock medicine, and dental care.

An update of the National Safety and Quality Health Service hospital standards for accreditation is in progress. The standards for AMS programs are set to be further refined in light of hospitals’ experience of implementation. There is likely to be an emphasis on delineating restriction rules and approval processes, auditing and providing feedback to prescribers, and monitoring the appropriateness of use.

The national clinical care standards for AMS released in 2014 are directed towards individual prescribers and their patients. These standards are intended to ensure that practitioners use best practice when prescribing antimicrobials, and that patients are properly informed about appropriate antimicrobial use.

These are huge achievements and help to increase awareness and clearly define expectations regarding antimicrobial use. Prescribers and consumers are being asked to rethink the way we approach antimicrobial drugs, to recognise that they are a “precious resource”, and that their use needs to be rationalised to ensure that they are protected and remain effective for future generations.

Auditing antimicrobial prescribing practices in Australia

In order to take action to improve prescribing practices, we first need to understand what is currently happening and then identify where improvement is required. Gathering such data has previously been very problematic. A large body of work has been undertaken by the National Centre for Antimicrobial Stewardship (NCAS) to develop standardised auditing tools that will help provide more meaningful data on the appropriateness of antimicrobial use.

The National Antimicrobial Prescribing Survey (NAPS) is a voluntary audit undertaken annually by hospitals from across Australia. It provides a snapshot of antimicrobial prescribing across public and private hospitals of all sizes, in different geographic locations, and with varied levels of expert support. The audit enables assessments of the appropriateness of prescriptions, and is a key component of the incipient Antimicrobial Use and Resistance in Australia (AURA) Surveillance System, which the ACSQHC has established with funding from the Department of Health.

International studies often cite that half of all antimicrobial prescriptions are inappropriate. In fact, the Australian NAPS done since 2013 show that Australia has higher appropriateness rates, at around 70% (although a goal of more than 95% has been set). Poor prescribing has been identified in certain areas, such as the treatment of respiratory infections (e.g., chronic obstructive pulmonary disease) and surgical prophylaxis. These findings help to target the activity of AMS programs within hospitals, and can directly inform broader initiatives such as national guidelines.

The survey’s remit, hitherto only encompassing hospitals, has now been extended to the aged care sector as well. A report released in 2016 and based on an audit of Australian aged care facilities showed disturbing rates of prolonged antimicrobial prescriptions and poor documentation of indications for use among residents.

Areas of need

It has been shown that the rates of antimicrobial prescribing in the Australian community on a per capita basis are about 10% above the Organisation for Economic Co-operation and Development average. We do not, however, have a detailed understanding of the appropriateness of such prescribing, and thus the areas requiring action are not yet entirely clear. There is an urgent need to gather such data and to meaningfully analyse it to drive improvement activities. NPS MedicineWise has been an active group in this area, but more action is urgently required.

Similarly, the level of detail on antimicrobial usage in the veterinary and agricultural sectors is currently inadequate in Australia. Although data on volumes of drugs imported for animal use confirm that Australia has very low levels of antimicrobial use, the reasons for use and the appropriateness of such use are poorly understood. NCAS is undertaking research into antimicrobial usage for both companion animals and livestock.

Another challenge facing AMS researchers in Australia is the lack of data linkage between antimicrobial usage and antimicrobial resistance. The patterns of pathogens being identified in patients are likely to be influenced by patterns of antimicrobial drug exposure in the local environment (for humans, animals and agriculture). To date, we have a poor understanding of the interrelationships between these.

How do we improve prescribing behaviour?

There is no doubt that urgent action needs to be taken to improve prescribing behaviours. In busy health care settings, we know that to be successful, AMS solutions must ultimately fit comfortably into the clinical workflow. Information technology, therefore, will play a crucial role – either at the “front-end”, providing decision support about antimicrobial choice, or at the “back-end”, aggregating data for effective and useful reporting.

One program, Guidance, developed at the Royal Melbourne Hospital, has been adopted by over 60 hospitals across Australia since 2005 to assist their AMS programs. As the innovation arm of NCAS, the Guidance team are now working with hospitals to implement electronic management systems for AMS. A key aim is to support interoperability between hospital systems, stewardship programs and NAPS. It is imperative that community prescribing software follows suit. It should be integrated with appropriate decision support to promote better prescribing practices in accordance with Australian recommendations. This will, however, need to be guided by careful health services research to ensure that solutions meet the needs of prescribers across each health care sector.

It is important to recognise that antimicrobial stewardship is not just about the prevention of antimicrobial resistance; its focus, first and foremost, is patient safety.

Professor Karin Thursky is the director of the NHMRC-CRE National Centre for Antimicrobial Stewardship, director of the Guidance Group at the Royal Melbourne Hospital, and deputy head of Infectious Diseases at the Peter MacCallum Cancer Centre in Melbourne.

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