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AN expert commentary published in Clinical Microbiology and Infection (CMI) has highlighted the urgent need to support and fund teams of specialist health workers (including infectious diseases specialists, microbiologists, pharmacists and nurses) for antimicrobial stewardship (AMS) in hospitals and the community.
In this article, we argue that investment in AMS teams is key to optimising infection control practices, improving clinical outcomes and preventing the rise of resistant pathogens.
AMS teams can undertake a number of critical functions, such as providing expert guidance to prescribers and health care providers, monitoring antimicrobial use and resistance, instituting and managing approval and audit processes and delivering staff education.
The CMI commentary, whose lead author is Professor Céline Pulcini, secretary of the European Society of Clinical Microbiology and Infectious Diseases’ Study Group for Antimicrobial Stewardship, and an infectious diseases physician at Nancy University Hospital and University of Lorraine, France, brings together perspectives from clinicians around the world, which highlight the importance of investing in specialised staff and resources for infection control and antimicrobial stewardship in health care settings globally.
As one of the authors, I would like to elaborate on how this specifically applies to Australia.
AURA (Antimicrobial Use and Resistance in Australia) 2017: second Australian report on antimicrobial use and resistance in human health, released on 3 August 2017, presents a comprehensive overview of the results of various programs dedicated to surveillance of antimicrobial use and resistance in Australia.
The National Antimicrobial Prescribing Survey (NAPS), which is annually conducted by our team at the National Centre for Antimicrobial Stewardship-Guidance Group, measures the quality of antimicrobial use in hospitals. The 2015 NAPS found that, on any given day in Australian hospitals in 2015, on average, 40.5% of patients were being administered an antimicrobial. Around 23% of antimicrobial prescriptions were found to be noncompliant with guidelines, and 21.9% were considered inappropriate.
We know that antibiotics for surgical prophylaxis are often given for too long. In 2015, 40.5% of surgical prophylaxis prescriptions captured in the NAPS were deemed inappropriate, mainly because of incorrect duration (29.9%) and incorrect dose or frequency (27.6%); or because they were given for a procedure that does not require antibiotics (22%). Almost 40% of cefalexin prescriptions in hospital were deemed inappropriate, and the most inappropriate use of cefalexin was for surgical prophylaxis, urinary tract infections and pneumonia.
The Aged Care NAPS (AcNAPS) program looks at antimicrobial prescribing and infections in residential aged care facilities (RACFs). The 2015 Aged Care NAPS pilot, in which 186 RACFs participated, found that 65% of prescriptions did not have a documented review- or stop-date, and that 31% of antimicrobial prescriptions were given for more than 6 months. In about 32% of cases, the indication or reason for the prescription was not written in the notes; and about 20% of prescriptions were for residents who did not have any visible signs and symptoms of infection.
Changes in antimicrobial resistance patterns are being monitored. Compared with 2014, there has been an increase in fluoroquinolone resistance in Escherichia coli (+2.5%) and Shigella sonnei (+10.9%).
Carbapenemase-producing Enterobacteriaceae (CPE) and Vancomycin-resistant enterococci (VRE) are notable among pathogens of concern in Australia, as is community-acquired methicillin-resistant Staphylococcus aureus (MRSA).
The launch of AURA 2017 provided leading clinicians and policy-makers another opportunity to deliberate on the next steps for Australia.
It is important to note that Australia has made notable progress in the field of AMS.
Since the introduction of AMS as a key criterion in the Australian Commission on Safety and Quality in Health Care’s hospital accreditation standards in 2013, Australian hospitals have been required to show that they have taken essential steps towards better management of antimicrobial use.
Localised development, implementation and reinforcement of policies on medication use, and enhanced staff education (aimed at familiarising prescribers, nurses and infection control practitioners with guidelines on antimicrobial use and restrictions) have been shown to be effective interventions.
Regular auditing, including through the NAPS (since 2011), which, as mentioned earlier, assesses the quality of antimicrobial use by measuring concordance with prescribing guidelines and appropriateness of prescribing, has led to increased awareness of patterns of prescribing and the identification of areas that require improvement. These steps towards better management of antimicrobial use have been facilitated by investment in staff and infrastructure.
While hospitals recognise the value of establishing and directing resources towards specialised AMS teams, the process is being hindered by the complexities of the jurisdictional health care system, as well as the disparities between rural/regional hospitals and well-resourced tertiary hospitals.
In our paper in CMI, we presented an overview of the results of our survey on national staffing standards for antimicrobial stewardship in 26 countries.
In Australia, there is currently no consensus on staffing recommendations within the national accreditation standards. However, as documented in Antimicrobial Stewardship in Australian Hospitals, a publication of the Australian Commission on Safety and Quality in Health Care, clinicians in hospitals with existing programs suggest that for every 100 acute beds, at least 10 hours (0.3 full-time equivalent [FTE] units) of senior pharmacist time and 3.5 hours (0.1 FTE) of lead clinician time per week should be dedicated to AMS activities. A minimum of 4 FTE per 1000 acute-care beds is recommended. For rural and regional hospitals, access to experts through networks or telehealth is recommended.
In some European countries, such as the Netherlands, Belgium and France, AMS is well-embedded in clinical practice. In the Netherlands, AMS is considered part of the baseline standard of care, and FTE staffing figures are not routinely specified. In Belgium, the federal government provides dedicated funding to all acute-care hospitals and chronic-care hospitals with over 150 beds to hire a trained antibiotic treatment manager for their AMS team. In France, hospital AMS programs are often underpinned by well-defined programs of core activities, including daily advice to prescribers. Hospital-based AMS specialists are also expected to participate in regional outpatient networks.
We believe that consensus on a list of activities for AMS and workforce needs is required. The ‘gold standard’ involves teams that include infectious diseases specialists, microbiologists, pharmacists, and nurses.
Most Australian states have committed to statewide programs to coordinate the implementation of AMS. In Victoria, following the publication of the Duckett report in 2016, there has been a focus on safety and quality in health care and a new drive towards a statewide approach.
AMS teams at many large tertiary hospitals are led by infectious diseases physicians and clinical pharmacists. Some smaller and regional hospitals, lacking specialist infectious diseases support, have nurses and infection control practitioners leading AMS initiatives, usually as part of another role.
A national survey undertaken by the National Centre for Antimicrobial Stewardship highlights that approximately 50% of respondent hospitals (301) have funded time allocated for AMS. This study, when published, will provide granular details on resource allocation for AMS in the Australian hospital sector.
Antimicrobial stewardship is a labour-intensive service that requires sufficient resources to effectively monitor prescriptions. Our best hospital IT systems cannot substitute for expert review and oversight of antimicrobials once they have been prescribed. We know from the NAPS data that one in four prescriptions is inappropriate. Once you consider that about 40% of inpatients are actually on an antibiotic at any point in time, you can understand the magnitude of our task.
Investment in resources such as decision support and audit tools is also important. The use of decision support, approval and post-prescription review tools has been associated with improved prescribing patterns and patient outcomes, and lower drug acquisition costs.
It is anticipated that an update of the hospital accreditation standards will be implemented in 2018, and there is likely to be renewed emphasis on refining elements such as approval processes and auditing.
While the hospital sector in Australia has seen considerable progress, much more can be done to improve prescribing in primary care and the community, and in veterinary and agricultural settings. The private sector is also under pressure to introduce AMS services as part of the accreditation framework. However, determining the cost effectiveness of AMS is a difficult undertaking, and business cases for comprehensive AMS remain a “hard sell” for many institutions in the current climate.
This CMI commentary by our colleagues from around the world brings renewed focus on global imperatives for greater investment in specialised infectious diseases and AMS expertise in health care settings – for improved management of antimicrobial use, and the preservation of the effectiveness of existing and new antimicrobial drugs.
It is important to remember that AMS is, first and foremost, about enhancing patient safety and improving health outcomes.
Professor Karin Thursky is the director of the National Health and Medical Research Council Centres of Research Excellence’s 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.
(with Dr Arjun Rajkhowa, NCAS centre manager)
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Yes we are sitting. Not waiting but regulating, bean counting, criticising, blaming, vilifying and politicising while we should be innovating. Sometimes I feel like the infection control people should carry a back pack full of handgel to squirt to the clinicians and the pharmacists should carry along with them a type writer to ‘legibly’ type the ‘generic’ name of the drugs the doctor says instead of criticising the doctors for not handwashing enough or not writing legibly enough. That would save at least the 12 hours of handwashing and the other 12 hours of documenting that is spent in a day!
Sorry to hear your story which is not uncommon – in vitro sensitive while in vivo, no effect! There is a lot left to be answered in these situations. The cost-benefit of AMS will be promptly gone when they question brand substitution and bio efficacy of such drugs! The retrospective chart analysis (aka auditing) sort of research that the funds for ams is funnelled to should be stopped. Sitting in glass houses these sort of researchers are simply separated from reality where the bugs are constantly innovating. Perhaps there should be a new goal-focussed mission to develop new therapies/antibiotics – money could be better spent for such an initiative.
Let me change the subject. I am not a specialist, scientist or clinician, just a person who suffers from ongoing regular Ecoli UTI infections and most of the lab listed antibiotics that my infection is supposed to be sensitive to do not work on me. I believe that our way forward is to research vaccines or immunological solutions and fast. As I believe that we will very soon be experiencing mass deaths due to all types of antibiotic resistant bacteria and organisms. I know that pharmaceutical companies do not support this research due to reduction on financial gain. They rather sell more useless antibiotics. But we must look at other types of immunotherapy e.g. Gardasil and consider the fact that there will always be new generations that will need treatment so there will be an on going number of customers. Of course this may not bring in as much money as sale of antibiotics, but considering the fact that existing antibiotics will very soon be useless maybe companies could consider the fact that their profits will soon dry up anyway. So what I would like to know is Australia also contributing to the research on other treatments e.g. immunological. Something to improve vastly on the European & other older products such as URO-Vaxom. Maybe something in the form of an inoculation ? Or are we just sitting back and waiting. Yes it takes a considerable amount of time, effort & money to do this research, but if not for the sake of the current generations like myself who probably already have our days numbered then for future generations after all they could be your grandchildren or great grandchildren.
AMS is one arm of the fight against AMR. It is an important one. Yes, clinicians working on the ground know and understand that AMS is about patient safety, and about getting the right drug to the patient on time. I’m sorry you experienced delayed treatment for a patient. However, AMS is about ensuring timely and appropriate treatment. Research on drug development and therapeutics is being done. Research on appropriate use needs to continue.
Something being touted as too good! Regulation is always good especially for the regulators! Well, dial the years forward after your ams had been stringently applied. Your repertoire of antibiotics would not have grown because a) You stifled new antibiotic research b) because you disincentivised the drug companies by restricting the market c) and disadvantaged the drug companies by supporting counterfeit drugs d) and made no effort to research on new antibiotics outside of drug companies. And when our future descendants deterministically thought all is well in the best of all worlds, there might come a microbe (ex. by air travel) that will not respond to every single granny potion there is in the closely guarded precious little cabinet of theirs handed over by us. I hope to be proved wrong. But, is all your ‘goodness’ based on some general data on C.diff? – what applies to the ‘general’ doesn’t apply to the ‘particular’ situation such as the above. Unlike you, I am a clinician who faced a real problem. If you do not believe it, you have every right to live in the world of your own! At least I am happy that you do dispense antibiotics on prescription. The quest for reliable source identification set aside, do you have the proof of bio equivalence of substituted drugs? I am no supporter of any one, but if I am a drug company, I would silently close my antibiotic labs in a climate such as this. Good luck.
I am an antimicrobial stewardship pharmacist working in the UK. I think that building AMS into hospital standards is the way forward and I find it disheartening to hear people describing it as “draconian regulation”.
In the UK over the past few years and for the next few years we have had national targets for each hospital to reduce their antimicrobial consumption, particularly focusing on pipercillin-tazobactam and carbapenems. We also focused on having a proper senior review within 72 hours of IV antimicrobials to assess their appropriateness. These targets were also alongside another program ensuring that septic patients were appropriately recognised and given antibiotics within 1 hour. So we are ensuring that sick patients are properly treated, but that we don’t just continue broad spectrum antimicrobials in those that don’t need them.
This has been a successful program so far and has seen a 10% reduction in c.diff nationally.
Specifically in my hospital there is a hospital wide program just started which aims to prevent all avoidable bloodstream infections in our patients. So far non of this is involving the increased use of antimicrobials, but in fact looking to reduce IV antimicrobials so to reduce the need for invasive devices – the entry points for microbes into our bloodstream.
For those that think that AMS does not work, have obviously not seen a good AMS program in action. Better patient outcomes, whilst reducing antimicrobial consumption is a win for all.
I would also like to see the evidence that non-branded antimicrobials are inferior to the branded versions and who this “reliable source” is
Can I open a can of worms here – Drug companies don’t make any effort likely because of the rampant patent violation in emerging markets. Years of their R&D is snatched by someone else so where is the point of spending more to develop new antibiotics. And we, one of the richest of countries in the world, support substituted non-branded items. When copying music is such an infringement, copying original pharmaceutical patent is not. Such copied patents lead to substituted substandard antibiotics – I learnt from a reliable source that the bio efficacy is variable in such substituted products upto 20%. So, bean counters contribute to brewing of resistance by preferring such substituted cheaper antibiotics. You know that the likelihood for brewing resistance is higher in sub-therapeutic concentrations. If the original potency was maintained by having the guaranteed product and appropriate dosage is maintained according to clinical situations, there probably is less risk for a resistant bug to emerge. My two cents. Will AMS tackle this problem? Importantly, AMS should not interfere with timely dispensing of antibiotics especially in emergent and life-threatening situations, as long as the treating specialist had exercised their rationality. I am being a part of the solution by pointing to the fundamental flaws having seen them in reality. Its upto you to take it or not in the positive light. What if it was your loved one in the above true scenario? The ‘cup is half empty’ pessimism of narrow minded and short-sighted regulator leading to locking of the cabinets will get us nowhere.
I’m sorry “anonymous” but you are very wrong about a whole bunch of things you have said. Australia has a comprehensive strategy at antimicrobial resistance that looks at all aspects of antibiotic overuse, encompassing the Agricultural and Vet sectors as well as Human Health. Australia has a much higher per capita than most other countries for prescribing antibiotics. When I am auditing I find patients who have been on IV antibiotics for over 10 days with no signs or symptoms of infection and probably never needed them in the first place. There is an over reliant culture on antibiotics and science is now showing us that this over reliance has very dire consequences as well. As recent study showed that antibiotics killed off helpful microbiota and inhibited neutrophils thus weakening the immune system. Cases if C. diff are increasing as are multi-resistant bacteria in our antibiotic rich environment. Sure we need to innovate, but don’t kid yourself, antibiotics don’t make drug companies money, so they aren’t even looking for new antibiotics. The innovations are coming from research and it takes years or even decades for new treatments to be proven as safe for human therapy. And, Yes MRO’s come into Australia via travellers but gene sequencing is showing we are growing them here to. It wont be long before we get patients that we have nothing left to treat them with. So what do you say when you are faced with that patient? What it that is your loved one? So you can just dig your heels in and say “this is draconian”, or you can try and learn about why AMS has evolved to what it is now, and try and be part of the solution.
Bacteria will become resistant whether you prescribe rationally or irrationally! Thanks for acknowledging that the current ams is offensive. The above is a true case scenario. Innovate or perish!
I’m not aware of anyone who has refused to approve/dispense an appropriately prescribed antibiotic for a progressively deteriorating septic patient. What I have seen time and time again is prescribing an overly broad spectrum antibiotic without justifying/documenting why it is needed – it seems so commonplace that people are up in arms if the prescriber is simply asked why. Antibiotics for sepsis should be readily accessible in all acute care settings. Local hospital-level antibiograms can help to determine which antibiotics are most suitable for the local patient population.
If everyone prescribed antibiotics judiciously, there would be no need for restrictive antimicrobial stewardship strategies but unfortunately evidence from NAPS and AURA reports suggests this isn’t happening. Point-of-care decision support, access to guidelines, post-prescription review, education and surveillance are antimicrobial stewardship strategies too. Once prescribing becomes more in line with best practice, we can focus more on the strategies that prescribers find less offensive.
Fear based Medicine had superseded evidence based medicine that’s all. I will give you one example : after exercising all ‘rational’ thought and taking into account all available culture results, a specialist decides to change the antibiotic on a progressively deteriorating septic patient but an id doctor who does not even see the patient prevents a pharmacist from dispensing the medication abusing this ams scheme. Only after overriding this disembodied irrational voice putting a blockade and pointing to the pharmacist’s dereliction of duty if they dont dispense to a specialist’s prescription , that the antibiotic gets dispensed albeit very delayed (not at all a fancy antibiotic, but they have made it class C only recently haha). Surprise surprise the patient improves. I have more examples. I wonder what makes such blockades ‘rational’! A regulator did not invent the first penicillin (nor does he have the brains to invent anything other than a crappy piece of policy) – and only comes into the scene when it becomes a successful invention to stifle the benefits! The money spent on ams be better directed to new antibiotic research.
Just to note, when you have patients coming in to our hospitals with untreatable infections, this whole thing becomes quite real. It’s not about blame, etc. It’s about those untreatable infections, and making sure that what we currently have continues to work in the short, medium and long term.
Agreed that vilification of any one or the other group does not get results. People need to be persuaded. Research looking into specific patterns of use is absolutely necessary. Look at the data above. Is it feasible to allow prescriptions to continue beyond six months in aged care homes? This is not about imposing unreasonable regulations. This is about identifying the areas that could be improved (considerably). And making those improvements stick.
Regulation is inferior to innovation. How many years are you going to be satisfied with the serendipitous invention of Penicillin? The whole ams seems to be a plan by identity devoid (Id) doctors who do not face the hot coal face but become an impediment in timely deliver of antibiotics. I do have evidence of harm but cannot be disclosed here. Sacrificing an individual for an unquantifiable common good is not ethical mate. Vilifying Gps as irrationally prescribing antibiotics is also not acceptable. Again I am not against rational antibiotic use but ams is becoming irrational where it hinders timely antibiotics and when it morphs into a regulatory monster.
“don’t make it a draconian regulation that is already harming critically unwell patients”
Some evidence for this comment would be good. There is nothing in the stewardship guidelines that denies antibiotics to the critically unwell patient, there is some pressure for rational initial choice and then subsequent review/pruning of antibiotics.
We will not make any progress with antibiotic stewardship by being polite about it, as our behaviours are so bad and so ingrained that they are very hard to shift. We have to recognise also that one of the key indications for antibiotic use is as a tranquiliiser for the doctor – we are so afraid of missing something that we prescribe “just in case” , prescribing more widely than we should or prolonging the course “just in case”.
This all becomes a self-fulfilling prophecy – prescription “just in case” leads to resistance and the “need” to use broader spectrum antibiotics “just in case” and it all snowballs off down the hill. We managed to deal with a significant resistance problem many years ago in a very busy NICU by a policy of only using penicillin, gentamicin and flucloxacillin, with anything else only on consultant authorisation ( not freely given ). The first year or so was a bit sweaty, but since then we have had very few problems with resistant organisms, any high level bugs having come predominantly from outside ( usually from mothers managed in adult hospitals ). It remains a constant battle because of community acquired organisms, but is one well worth having (there is no alternative)
It should also be noted that the agricultural industries are massive offenders on this front, generating a large pool of organisms exposed to high level antibiotics . We are still doing very little of any value on dealing with this and there is considerable resistance to change.
The “develop more antibiotics” argument is doomed to fail. There are few, if any, in the pipeline and they will suffer the same fate as those which went before, unless somethng very fundamental changes. There is not vast effort to develop new ones – most people who die of infection are poor and can’t pay, so no point there, most in affluent countries who get infected are either dead or better in a couple of weeks, so not much money there. Far better to develop “me too” drugs to help fat middle aged men keep their blood pressure and cholesterol down and their penises up, as we have the money to pay and will do so happily for years.
This is only going to change with just the sort of regulation and pressure you abhor. It is a very fundamental fight.
While I support rational use of Antibiotics I violently detest a draconian regulation emerging under the cover of a ‘stewardship’. Timely antibiotic administration is delayed in life threatening situations. Innovate like the microbe – invent new antibiotics. Please do not regulate without understanding clinical situations. The very fact of awareness should be the end point of your stewardship. There are countries where you can get a popsicle made of tigecyline-anidilafungin-ganciclovir at a street corner pharmacy without a doctor prescription! And air travel spreads all those multi resistant bugs to everywhere else. Veterinary medicine is yet another brewing ground for resistance. It is foolish to think your stewardship will stop resistance in such a world! Bottom line – keep it as stewardship- don’t make it a draconian regulation that is already harming critically unwell patients