Antimicrobial Stewardship in Australian Health Care 2018 Published by the Australian Commission on Safety and Quality in Health Care Level 5, 255 Elizabeth Street, Sydney NSW 2000 Phone: (02) 9126 3600 Fax: (02) 9126 3613 Email: Antimicrobial Stewardship in Australian Health Care 2018 Acknowledgements Antimicrobial Stewardship in Australian Health Care • Professor Graeme Nimmo – Pathology 2018 has been developed through the contributions Queensland, Queensland Health (particularly of many individuals and organisations who are Chapter 9) committed to improving antimicrobial use in • Professor Lisa Pulver – NPS MedicineWise hospitals and reducing the risk of harm to patients (particularly Chapters 7 and 10) from inappropriate antimicrobial prescribing. • Professor Debra Rowett – NPS MedicineWise The Australian Commission on Safety and Quality (particularly Chapters 7 and 10) in Health Care wishes to thank the following • Professor Karin Thursky – National Centre contributing authors for their expertise and time for Antimicrobial Stewardship (particularly given to the writing of this publication: Chapter 4) • Dr Tara Anderson – Infectious Diseases Physician • Professor John Turnidge – Australian and Clinical Microbiologist, Medical Advisor Commission on Safety and Quality in Health – Infection Prevention and Control, Royal Care (particularly Chapters 1 and 3) Hobart Hospital, and Specialist Medical Advisor • Dr Helen Van Gessel – Albany Hospital – Tasmanian Infection Prevention and Control (particularly Chapter 2) Unit (particularly Chapter 2) • Dr Morgyn Warner – SA Pathology, SA Health • Dr Noleen Bennett – National Centre for (particularly Chapter 1) Antimicrobial Stewardship (particularly • Dr Jeanie Yoo – NPS MedicineWise (particularly Chapter 12) Chapter 10). • Associate Professor Kirsty Buising – National The Commission also wishes to extend its thanks to Centre for Antimicrobial Stewardship the following individuals who have provided their (particularly Chapters 3 and 6) considered advice in the review of the content of this • Clinical Associate Professor Susan Benson book: – PathWest Laboratory Medicine, Western • Dr Philippa Binns – public health physician and Australian Department of Health and University general practitioner of Western Australia (particularly Chapter 9) • Professor Chris Del Mar – Centre for Research in • Dr Celia Cooper – SA Pathology, SA Health Evidence-Based Practice, Bond University (particularly Chapters 5 and 8) • Dr Kylie Easton – NPS MedicineWise • Dr Jonathan Dartnell – NPS MedicineWise (particularly Chapters 7 and 10) • Associate Professor Thomas Gottlieb - Senior Staff Specialist, Microbiology & Infectious Diseases, Concord • Ms Margaret Duguid – Australian Commission on Hospital Safety and Quality in Health Care (contribution to all Chapters) • Dr Malene Hansen – Centre for Research in • Conjoint Associate Professor John Ferguson Evidence-Based Practice, Bond University – Hunter New England Local Health District • Ms Dorothy Harrison – consumer representative (particularly Chapter 9) reviewer • Ms Fiona Gotterson – Australian Commission on • Ms Aine Heaney – NPS MedicineWise Safety and Quality in Health Care (particularly • Ms Elaine Lum – Institute of Health and Chapters 3, 5 and 12) Biomedical Innovation, Faculty of Health, • Dr David Kong – Ballarat Health Services and Queensland University of Technology Centre for Medicine Use and Safety, Monash • Dr Amanda McCullough – Centre for Research in University (particularly Chapter 11) Evidence-Based Practice, Bond University • Associate Professor David Looke – Infectious • Dr Geoffrey Playford - Director, Infection Diseases Physician and Clinical Microbiologist, Management Services, Princess Alexandra Hospital Princess Alexandra Hospital; and Associate Professor, University of Queensland (particularly • Associate Professor Owen Robinson - Infectious Chapter 6) Diseases Physician, Royal Perth Hospital iii • Ms Vanessa Simpson – NPS MedicineWise • Dr Andrew Staib - Emergency Medicine, Princess Alexandra Hospital • Dr Clair Sullivan - Consultant Endocrinologist and Medical Informatician, Princess Alexandra Hospital. A number of Commission staf were also involved in the writing and review of this publication, and the Commission wishes to acknowledge: • Ms Debbie Carter • Professor Marilyn Cruickshank • Dr Nicola Dunbar • Dr Robert Herkes • Ms Eliza McEwin • Adjunct Professor Kathy Meleady • Adjunct Professor Debora Picone AM • Ms Naomi Poole • Ms Lucia Tapsall • Mr Michael Wallace. In addition, the Commission wishes to acknowledge the members of the Society of Hospital Pharmacists of Australia Infectious Diseases Committee of Specialty Practice for their contribution in reviewing this publication; and the staf of Biotext for their expert review, editing and design services. iv Contents Acknowledgements iii Summary 1 Key issues 3 The challenge 3 The response 3 Australian framework for AMS 3 Essential elements of antimicrobial stewardship 3 This publication 4 Aim 4 Structure 4 Chapter 1: Evidence for antimicrobial stewardship 7 Acronyms and abbreviations 10 1.1 Introduction 11 1.2 Challenge and impact of antimicrobial resistance 12 1.2.1 Association between antimicrobial use and resistance 12 1.2.2 Consequences of antimicrobial resistance 13 1.3 Australian framework for antimicrobial stewardship 14 1.3.1 National standards and guidelines 14 1.3.2 National Antimicrobial Resistance Strategy 17 1.3.3 Antimicrobial stewardship in the states and territories 17 1.3.4 Therapeutic Guidelines 17 1.3.5 Surveillance of antimicrobial use and resistance in Australia 18 1.3.6 Education and awareness raising 19 1.3.7 Antimicrobial stewardship research 20 1.3.8 Professional societies and organisations 20 1.4 Antimicrobial use 21 1.4.1 Factors contributing to unnecessary and inappropriate antimicrobial use 21 1.4.2 Antimicrobial use in Australia 21 1.4.3 Harmful efects of antimicrobial use 21 1.5 Antimicrobial stewardship 22 1.5.1 Efective antimicrobial stewardship 22 1.5.2 Evidence to support the benefts of antimicrobial stewardship 24 1.5.3 Unintended consequences of antimicrobial stewardship programs 27 References 29 Appendix A: Examples of antimicrobial stewardship (AMS) activities and resources in Australian states and territories 34 v Chapter 2: Establishing and sustaining an antimicrobial stewardship program 35 Acronyms and abbreviations 38 2.1 Introduction 39 2.2 Essential elements of antimicrobial stewardship programs 40 2.3 Structure and governance 41 2.3.1 Safety and quality improvement 41 2.3.2 Governance 41 2.3.3 Executive leadership 44 2.3.4 Clinical leadership 44 2.4 Antimicrobial stewardship committee and team 45 2.4.1 Antimicrobial stewardship committee 45 2.4.2 Antimicrobial stewardship team 48 2.5 Antimicrobial stewardship program plan 49 2.5.1 Assessing readiness to implement an antimicrobial stewardship program or intervention 49 2.5.2 Reviewing existing policies and prescribing guidelines 53 2.5.3 Reviewing local data on antimicrobial use and resistance 55 2.5.4 Determining priority areas for antimicrobial stewardship activities 56 2.5.5 Identifying efective interventions 57 2.5.6 Defning measurable goals and outcomes 58 2.5.7 Documenting and implementing the antimicrobial stewardship plan 59 2.5.8 Educating the workforce 59 2.5.9 Developing and implementing a communication plan 60 2.6 Sustaining the antimicrobial stewardship program 60 Resources 61 References 63 Appendix A: Examples of successful and sustained antimicrobial stewardship programs 66 Chapter 3: Strategies and tools for antimicrobial stewardship 75 Acronyms and abbreviations 78 3.1 Introduction 79 3.2 Prescribing guidelines 81 3.2.1 National guidelines 81 3.2.2 Local guidelines 81 3.2.3 Promoting guideline uptake 82 3.2.4 Tools and resources to support guideline implementation 82 3.2.5 Education and feedback 83 3.2.6 Antimicrobial stewardship care bundles 83 3.3 Formularies and approval systems 83 3.3.1 National formulary 83 3.3.2 State and territory formularies 84 3.3.3 Hospital formularies 84 3.3.4 Antimicrobial approval systems 85 vi 3.4 Post-prescription reviews 87 3.4.1 Who should perform reviews in hospitals? 87 3.4.2 Which patients should be reviewed? 89 3.4.3 What should be included in the feedback? 89 3.4.4 How should feedback be provided? 89 3.4.5 Prescription review at transitions of care 90 3.4.6 Post-prescription reviews in the community setting 90 3.5 Point-of-care interventions 91 3.5.1 Directing therapy based on results from microscopy and other rapid tests 91 3.5.2 Directing therapy based on culture and susceptibility test results 91 3.5.3 Optimising dosing 91 3.5.4 Limiting toxicity 92 3.5.6 Changing the duration of therapy 92 3.5.7 Switching from intravenous to oral delivery 92 3.5.8 Escalating to formal expert clinical review 93 Resources 94 References 95 Chapter 4: Information technology to support antimicrobial stewardship 99 Acronyms and abbreviations 102 4.1 Introduction 103 4.2 Electronic clinical decision support systems 104 4.2.1 Passive decision support systems and smartphone apps 105 4.2.2 Electronic approval systems 108 4.2.3 Electronic surveillance and infection prevention systems 109 4.2.4 Electronic prescribing and medication management systems 110 4.2.5 Advanced decision support systems 111 4.2.6 Implementing electronic clinical decision support systems for antimicrobial stewardship 112 4.2.7 Electronic clinical decision support in primary care 113 4.3 Data collection and reporting 114 4.4 Telehealth 115 Resources 117 References 118 Chapter 5: Antimicrobial stewardship education for clinicians 123 Acronyms and abbreviations 126 5.1 Introduction 127 5.2 Key elements of antimicrobial stewardship education 128 5.2.1 Audiences 128 5.2.2 Principles of education on antimicrobial stewardship 129 5.2.3 Antimicrobial stewardship competencies and standards 129 vii 5.2.4 Infuence of the pharmaceutical industry 131 5.2.5 Evaluation of educational activities 132 5.3 Antimicrobial stewardship education for diferent groups and stages 132 5.3.1 Undergraduate training 132 5.3.2 Early-career development 133 5.3.3 Continuing education and professional development 134 5.3.4 Education and training for antimicrobial stewardship teams 136 5.3.5 Specialist training 137 5.4 Education resources 137 5.4.1 Guidelines 137 5.4.2 Websites and online learning resources 137 5.4.3 Educators 138 Resources 139 References 140 Appendix A: Managing conficts of interest and relationships with the pharmaceutical industry – further reading and links 143 Appendix B: Example of a ‘Did you know’ email for clinicians 144 Chapter 6: Measuring performance and evaluating antimicrobial stewardship programs 147 Acronyms and abbreviations 150 6.1 Introduction 151 6.2 Key elements of antimicrobial stewardship measurement 152 6.2.1 What should be measured? 152 6.2.2 Measurement approaches 152 6.3 Structure measures 152 6.3.1 Hospitals 152 6.3.2 Community 154 6.4 Process measures 154 6.5 Outcome measures 155 6.5.1 Improved patient outcomes 156 6.5.2 Improved patient safety 156 6.5.3 Reduced resistance 156 6.5.4 Reduced costs 157 6.5.5 Qualitative and other related measures of program activity 157 6.6 Balancing measures 157 6.7 Surveillance of antimicrobial use 158 6.7.1 Measuring the volume of antimicrobial use in hospitals 158 6.7.2 Measuring the volume of antimicrobial use in the community 160 6.7.3 Reporting and monitoring use data at the local level 161 6.8 Auditing the quality of antimicrobial prescribing 164 6.8.1 Auditing prescribing in hospitals 164 viii