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MONITORING the quality of antimicrobial use in aged care homes (ACHs) is important, as elderly residents are especially vulnerable to infections and, therefore, more likely to be receiving antimicrobial therapy.
The aged care National Antimicrobial Prescribing Survey (acNAPS) is an annual survey of antimicrobial prescribing practices in Australian ACHs. The primary aim of this survey is to help ACHs improve their antimicrobial use.
The results of the 2017 acNAPS survey, conducted between 19 June and 1 September 2017, have now been communicated to all 293 participating ACHs in order to facilitate local quality improvement initiatives.
The first acNAPS was piloted in 2015. Its findings have been detailed in a comprehensive public report. The results of the 2016 acNAPS are now also available in a report.
Data collection
On the day of the survey, nurses, pharmacists and infection control practitioners collect data about residents who have signs and symptoms of infection or have been prescribed an antimicrobial. To increase their sample size, some ACHs also choose to collect data about antimicrobials that were prescribed and completed in the month prior to the day of the survey. Data are collected from different sources, such as residents’ histories and medication charts, and are submitted to the acNAPS program at the National Centre for Antimicrobial Stewardship (NCAS) via the online data entry portal.
Findings from 2017
In 2017, the medication charts of 12 344 permanent, respite or transitional care residents were reviewed. On the day of the survey, the proportion of residents who were prescribed at least one antimicrobial was 8.9%, while the proportion of residents who had signs or symptoms of infection was 2.9%. Cephalexin (20.0%) was the most commonly prescribed antimicrobial. Skin or soft tissue (31.7%), urinary tract (26.7%) and respiratory tract (20.8%) infections were the three most common indications for prescribing antimicrobials.
Other key findings included:
- A high rate of use of antimicrobials for unconfirmed infections: almost one-third (33.2%) of antimicrobials were prescribed for residents who had no signs or symptoms of infection in the week prior to the antimicrobial start-date. Further, 51.6% of suspected infections did not meet the McGeer and colleagues criteria (a set of widely referenced and internationally recognised infection definitions that have been specifically developed for use in ACHs).
- Prolonged duration of prescriptions: almost one-quarter (21.8%) of antimicrobials had been administered for longer than 6 months.
- Widespread use of topical antimicrobials: topical antimicrobials accounted for over one-quarter (29.5%) of prescriptions.
- Incomplete documentation: the indication for the antimicrobial was not documented for 22.1% of antimicrobials administered, and the review- or stop-date was not documented for 49.3% of antimicrobials administered.
These findings show that there is scope for improvement of antimicrobial use in Australian ACHs.
Feedback
On completing their data entry, each ACH can generate customised reports and examine their local issues. Importantly, ACHs are able to undertake the acNAPS any time during the year for local use; however, only data collected during the official survey period are included in the public reports.
Participating ACHs are encouraged to report their results to residents and their carers, administrative and clinical staff, and off-site general practitioners and pharmacists. The underlying assumption is that these reports act as a platform to educate ACH residents and staff about appropriate antimicrobial use. They also provide an incentive to make clinical policy and practice changes, and can be presented to accreditation organisations as evidence of quality improvement initiatives. Considered together, these approaches are anticipated to yield better outcomes for residents.
Future acNAPS
Improving the safety and quality of care in the aged care sector is a national priority.
It is for this reason that it is recommended that all Australian ACHs participate in the acNAPS in 2018 and use it as a quality improvement tool. It is commendable that those ACHs that have previously participated are now developing and implementing antimicrobial stewardship strategies to address the problems identified.
acNAPS is a collaborative project between the NCAS, the Guidance Group (Royal Melbourne Hospital), the Victorian Healthcare Associated Infection Surveillance System Coordinating Centre (Royal Melbourne Hospital) and the participating ACHs. It is supported by funding from the Australian Commission on Safety and Quality in Health Care under the Antimicrobial Use and Resistance in Australia project.
Dr Noleen Bennett is the acNAPS Project Officer for the NCAS Written with the assistance of Dr Arjun Rajkhowa centre manager at NCAS.
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We respectfully disagree with many of your comments. On the question of conflating antifungals with antibiotics – the reports consistently mention ‘antimicrobials’ (a term that includes antibiotics, antifungals and antivirals), and the data separating antibiotics alone vs antimicrobials are provided separately in the report.
The NAPS platforms are designed primarily for local quality improvement activities within the facility, where a lot of the extra data needed for interpretation is available. Many facilities participating in the acNAPS have reported that extremely useful data for quality interventions have been uncovered.
In our view, the high use of topical antimicrobial agents is important. In many healthcare sectors (hospitals and community) much of this use was unrecognised prior to standardised auditing, and when more detail was sought, much of this use was found to be simply unnecessary. For example, topical antibiotics used as prophylaxis on clean wounds or skin tears confer no benefit and can be associated with skin irritation. This has led to some facilities developing policies to explicitly discourage use. Antimicrobials used via any route can be associated with the development of resistance.
Prolonged use of antimicrobial drugs in residential aged care is very real. The question of whether this is appropriate use needs further interrogation, which cannot be provided by this type of audit. What the audit can do is shine a light on areas that might prompt clinicians to ask questions. As an example, one facility that participated in acNAPS identified four residents who had received years of oral antibiotic therapy with no documentation of any likely indication in the medical record. In response, the charge nurse simply asked the treating doctors to review the prescriptions. These doctors consulted their practice notes, discharge summaries and specialist letters and decided that in all four cases, the antibiotic could safely be ceased with no adverse effects for the residents 4 months later. This is the action that an audit like acNAPS can prompt. It is a quality improvement tool that allows clinicians to receive feedback on what residents are actually being prescribed and reflect on this prescribing practice. The findings may or may not require intervention.
The design of the acNAPS has been overseen by epidemiologists, statisticians, doctors (including ID physicians and microbiologists), infection control experts, nurses, and pharmacists. Active feedback has been sought from staff at participating sites with whom we regularly interact to improve the tool to make it easy to use and to make the analysis most meaningful for them.
The annual report is a summary for the overall findings, and although it does not go into individual problem indications in too much detail, it is able to highlight areas for targeted education and quality improvement campaigns. The database itself is available for further data interrogation if these areas require in depth analysis. Analysis of a few of these areas is currently underway, and more targeted reports will be available soon.
The acNAPs reports are of suboptimal quality, and remedial measures need to be implemented to support logical analysis.
The authors are correct in noting the importance of this report, but this 2017 report suffers from same problems the 2015 and 2016 reports experienced.
Conflating systemic and topical antibiotic use makes statistics confusing and interpretation almost impossible. This is worsened by previous reports counting Clotrimazole, Miconazole, Ketaconazole and Terbenifine as topical antibiotics – where in fact they are antifungals.
Surely this sort of inaccuracy can be managed? Ie take out antifungals and separate systemic and topical antibiotic use?
The reports do not standardise for the clinical context. The samples are taken at the height of winter / flu season; the height of antibiotic prescribing. Prolonged antibiotics – are not a problem, rather a therapeutic reality for aged residents for urinary prophylaxis, infected joint prostheses and may other long term conditions. Yet it is painted as “a key finding”. Use of “antimicrobials in residents who had no signs of infection” or “unconfirmed infections” are hence poor indicators.
It appears the biggest finding in the report is incomplete documentation, but that is not justification for the finding that “findings show that there is scope for improvement of antimicrobial use in Australian ACHs. There needs to be improved medical judgement of these results in future.
The acNAP reports are suboptimal. The ACSQHC should take remedial action before further reports are undertaken. The reports should also undergo medical review to facilitate improved analysis.