Animals, agriculture and antimicrobial stewardship

NCAS • Jan 20, 2020

Arjun Rajkhowa, Kirsten Bailey, Laura Hardefeldt, Helen Billman-Jacobe, James Gilkerson and Glenn Browning


(Published in Medical Journal of Australia-Insight)


The rise of drug-resistant infections presents significant challenges globally. Antimicrobial resistance (AMR) threatens to jeopardise health care delivery through increased mortality and morbidity, length of stay in hospitals, and costs of hospitalisation. Effective treatment for infections fundamentally underpins all of health care. When this is irreparably undermined, health care outcomes will be detrimentally affected.


AMR is one of the definitive One Health problems of our times, spanning both human and animal health. Globally, practices that contribute to AMR, such as the misuse or suboptimal use of antibiotics, undoubtedly occur in both human and animal sectors.


However, agriculture is often portrayed in media reports as the prime culprit and the crux of the crisis.


Several misconceptions about Australian veterinary and agricultural antimicrobial use abound. Perhaps, in our attempts to grapple with the ramifications of the emerging crisis and apportion blame for it, we may occasionally misrepresent antimicrobial use in veterinary medicine in Australia. Outdated practices long since discontinued in Australia and inappropriate antibiotic use practices from overseas are discussed as if they occur here.


Are antimicrobials used for growth promotion in Australia?


An episode of Ask the Doctor on the ABC dealt with the issue of emerging AMR in people, but made some errors while discussing antibiotic use in animals. Most importantly, the presenters and featured (human health) experts suggested that antibiotics are used in every chicken, pig or cow for nearly all their lives.


All antibiotics that are important for human health that had previously been labelled for use for growth promotion have had those label claims removed in recent years in Australia. This means that these antibiotics can no longer be used for this purpose in food-producing animals in Australia.


Moreover, the program also represented the use of the “antibiotic-free” label in food production as a sort of panacea for perceived current problems.


While it is commendable that many farmers and producers have minimised their antibiotic use, it is still important that farm animals with bacterial infections are appropriately treated with antibiotics. Health and welfare outcomes for sick animals will suffer if antibiotics are not appropriately used when they are needed. We need to ensure that sick animals receive the treatment they need, while preserving the efficacy of antibiotics for future use.


Antimicrobials registered for use in agricultural animals in Australia


The threat posed by increasing rates of drug-resistant infections has made it necessary for us to ensure that critically important antimicrobials remain effective for humans into the future. This entails carefully regulating their use in animals.


Antimicrobials approved for use in Australia are different to those overseas. In particular, colistin and fluoroquinolones are not approved for use in food-producing animals, and no fourth-generation cephalosporins have been registered or approved for use in food-producing animals in Australia. Use of third generation cephalosporins is restricted.


Animal husbandry regulations in Australia are relatively quite advanced. Animal product residue monitoring is undertaken across production sectors, and antibiotics constitute one group of monitored drugs, alongside anthelmintics, hormones, corticosteroids, fungicides, herbicides and others. Antibiotic residue testing covers the major antibiotic classes. Withholding periods are intended to ensure that no residues remain in meat products when they are processed for human consumption. The national residue monitoring program reports high levels of compliance with the regulatory regime across sectors. The poultry sector, for example, is generally understood to have responsible use practices, and antibiotics are only sparingly prescribed to treat or prevent infections when other strategies have failed. Withholding periods are observed. No hormones or steroids are used in poultry.


While antibiotic residues are routinely monitored, bacterial contamination or bacterial resistance have only been assessed in small pilot and snapshot studies.


Antimicrobial stewardship


Antimicrobial stewardship (AMS) is a key element of the fight against the rise of “superbugs”. AMS ensures that antibiotic use is appropriate to treat the particular infection in the patient, and that critically important antibiotics are reserved to treat the most serious infections in people.


The National Centre for Antimicrobial Stewardship brings together medical and veterinary infectious disease experts in a One Health research program focused on preserving the effectiveness of antibiotics for the future.


Our research on antimicrobial use in animals in Australia has examined several key aspects of antimicrobial prescribing in veterinary medicine. The centre has undertaken studies to examine and appraise:


We are undertaking research on using information technology tools to extract antimicrobial usage data from medical records; using antimicrobial susceptibility information to assess the validity of guideline recommendations; developing infection control and AMS capacity among dairy farmers; and, most importantly, implementing an AMS trial across a nationwide network of clinics, where we provide resources to support different levels of AMS activities in different clinics to determine the acceptability and efficacy of targeted strategies.


We have developed clinical resources for veterinary AMS, including educational posters and antimicrobial prescribing guidelines for companion animal, equine and bovine practices, and these have been disseminated locally and nationally, with the support of Agriculture Victoria (which sponsored the development of these resources). Agriculture Victoria has supported efforts to disseminate these resources widely among veterinarians and farmers in Victoria. We have found engaging with veterinarians and farmers about AMS to be an overwhelmingly positive experience – there is a tremendous desire for more information and great support for the promotion of judicious antimicrobial use.


Our prescribing guidelines have also been assessed in a wide-ranging guideline-appraisal project, and we aim to use this to inform how we refine and use the guidelines.


A One Health approach to the problem


The Australian Government, through its National AMR Strategy (which, encouragingly, will be renewed later this year), has attempted to cohesively bring human and animal health sectors together to work collaboratively on tackling the problem of AMR.


This necessary effort has yielded considerable success, in that we now have a clinical, scientific and policy environment where cross-pollination and collaboration can occur. This can be further consolidated in the future.


However, at the moment, it is clear that we lack effective communication between different sectors, and there is still insufficient understanding, on either side, of the problems and challenges that affect the other. Conversely, we are also less aware about the myriad structural and environmental factors that may be seen as enablers of progress in this area in Australia.


Undoubtedly, the global ramifications of the problem of inappropriate antimicrobial use in agriculture are vastly more complex. As such, direct and unqualified comparisons between different geographical and political contexts may not be tenable.


Nevertheless, we can and must engage in nationally (and, ultimately, globally) coordinated efforts to improve veterinary education and training, and support initiatives focused on improving antimicrobial use in different countries. Our team, alongside others in Australia and New Zealand, has engaged in such work in the Asia–Pacific region. We recognise the importance of facilitating greater knowledge about optimal antimicrobial use in agriculture globally, and acknowledge that significant barriers to stewardship remain in many places.


That said, insofar as veterinary medicine in Australia is concerned, we should attempt to avoid convenient mischaracterisations, encourage timely reporting of actual antimicrobial usage in agricultural industries, and aim to more accurately identify the challenges that continue to act as barriers to AMS here.

Nurses: an underused, vital asset against drug-resistant infections

by NCAS • 03 Sept, 2022
Nurses: an underused, vital asset against drug-resistant infections Enrique Castro-Sánchez, Jo Bosanquet, Molly Courtenay, Rose Gallagher, Fiona Gotterson, Elizabeth Manias, Jo McEwen, Val Ness, Rita Olans, Maria Clara Padoveze, Briette du Toit & Miquel Bennasar-Veny Read the correspondence here , in response to Murray, C. et al Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis, also published in The Lancet (found here ). Citation : Castro-Sánchez, E., Bosanquet, J., Courtenay, M., Gallagher, R., Gotterson, F., Manias, E., ... & Bennasar-Veny, M. (2022). Nurses: an underused, vital asset against drug-resistant infections. The Lancet, 400(10354), 729. doi: https://doi.org/10.1016/S0140-6736(22)01531-8

A novel GPPAS model: Guiding the implementation of antimicrobial stewardship in primary care utilising collaboration between general practitioners and community pharmacists

by NCAS • 27 Aug, 2022
A novel GPPAS model: Guiding the implementation of antimicrobial stewardship in primary care utilising collaboration between general practitioners and community pharmacists Sajal K Saha, Karin Thursky, David C.M. Kong and Danielle Mazza Abstract Interprofessional collaboration between general practitioners (GPs) and community pharmacists (CPs) is central to implement antimicrobial stewardship (AMS) programmes in primary care. This study aimed to design a GP/pharmacist antimicrobial stewardship (GPPAS) model for primary care in Australia. An exploratory study design was followed that included seven studies conducted from 2017 to 2021 for the development of the GPPAS model. We generated secondary and primary evidence through a systematic review, a scoping review, a rapid review, nationwide surveys of Australian GPs and CPs including qualitative components, and a pilot study of a GPPAS submodel. All study evidence was synthesised, reviewed, merged, and triangulated to design the prototype GPPAS model using a Systems Engineering Initiative for Patient Safety theoretical framework. The secondary evidence provided effective GPPAS interventions, and the primary evidence identified GP/CP interprofessional issues, challenges, and future needs for implementing GPPAS interventions. The framework of the GPPAS model informed five GPPAS implementation submodels to foster implementation of AMS education program, antimicrobial audits, diagnostic stewardship, delayed prescribing, and routine review of antimicrobial prescriptions, through improved GP–CP collaboration. The GPPAS model could be used globally as a guide for GPs and CPs to collaboratively optimise antimicrobial use in primary care. Implementation studies on the GPPAS model and submodels are required to integrate the GPPAS model into GP/pharmacist interprofessional care models in Australia for improving AMS in routine primary care. Read the full paper here . Citation : Saha, S. K., Thursky, K., Kong, D., & Mazza, D. (2022). A Novel GPPAS Model: Guiding the Implementation of Antimicrobial Stewardship in Primary Care Utilising Collaboration between General Practitioners and Community Pharmacists. Antibiotics, 11(9), 1158. doi: 10.3390/antibiotics11091158

Influences on nurses’ engagement in antimicrobial stewardship behaviours: A multi-country survey using the Theoretical Domains Framework

by NCAS • 18 Aug, 2022
Influences on nurses’ engagement in antimicrobial stewardship behaviours: A multi-country survey using the Theoretical Domains Framework Angel Marie Chater, Hannah Family, Ligia Maria Abraao, Emma Burnett, Enrique Castro-Sanchez, Briëtte Du Toit, Rose Gallagher, Fiona Gotterson, Elizabeth Manias, Jo Mcewen, Rosely Moralez de Figueiredo, Martina Nathan, Val Ness, Rita Olans, Maria Clara Padoveze & Molly Courtenay Abstract Background Antimicrobial resistance (AMR) is significantly affected by inappropriate antibiotic use, and is one of the greatest threats to human health. Antimicrobial stewardship (AMS) is a programme of actions promoting responsible antimicrobial use, and is essential for limiting AMR. Nurses have an important role to play in this context. Aim This study investigated the determinants of nurse AMS behaviours and the impact of past training. Method A cross-sectional multi-country survey design with mixed methods was employed. Participants were 262 nurses (223 female; mean age = 44.45; SD = 10.77 years) from ten nationalities, with individual survey links sent via professional networks in 5 countries, alongside Twitter. Nine AMS behaviours and 14 behavioural determinants were quantitatively assessed using the Theoretical Domains Framework (TDF), and mapped to the COM-B (Capability, Opportunity, Motivation – Behaviour) model. Analysis identified differences between nurses with and without AMS training. The influence of COVID-19 on AMS behaviour was qualitatively investigated using free text data. Findings Nurses performed all nine AMS behaviours, which were significantly higher (t(238) = -4.14, p < .001), by those who had training (M = 53.15; SD = 7.40) compared to those who had not (M = 48.30; SD = 10.75). Those with AMS training scored significantly higher in all of the TDF domains. The TDF was able to explain 27% of the variance in behaviour, with ‘Skills’ and ‘Behavioural Regulation’ (e.g. ability to self-monitor and plan), shown to be the most predictive of AMS actions. Both of these domains are situated in the Capability construct of COM-B, which can be enhanced with the intervention strategies of education and training. An increase in AMS behaviours was reported since COVID-19, regardless of previous training. Six core themes were linked to AMS: 1) Infection prevention and control, 2) Antimicrobials and antimicrobial resistance, 3) The diagnosis of infection and the use of antibiotics, 4) Antimicrobial prescribing practice, 5) Person-centred care, and 6) Interprofessional collaborative practice. Conclusion This research, has identified the significant benefit of nurse training on AMS behaviour, and its determinants. Those who had training, scored higher in all TDF determinants of behaviour, compared to those who had had no training, resulting in higher Capability, Opportunity and Motivation to perform AMS behaviours. AMS education and training should be offered to nurses to enhance these factors. Future research should consider the optimal level of training to optimise AMS behaviour, with a focus on developing skills and behavioural regulation. Read the full paper here . Citation : Chater, A. M., Family, H., Abraao, L. M., Burnett, E., Castro-Sanchez, E., Du Toit, B., Gallagher, R., Gotterson, F. ... & Courtenay, M. (2022). Influences on nurses’ engagement in antimicrobial stewardship behaviours: A multi-country survey using the Theoretical Domains Framework. Journal of Hospital Infection. 2022 July. doi: https://doi.org/10.1016/j.jhin.2022.07.010

Prophylactic antimicrobial prescribing in Australian residential aged-care facilities: Improvement is required.

by NCAS • 17 Aug, 2022
Prophylactic antimicrobial prescribing in Australian residential aged-care facilities: Improvement is required

Improving management of urinary tract infections in residential aged care facilities

by NCAS • 07 Aug, 2022
Improving management of urinary tract infections in residential aged care facilities Lyn-Li Lim, Noleen Bennett Abstract Antimicrobial resistance rates are higher in Australian residential aged care facilities (RACFs) than other community or hospital settings. This is driven by antibiotic overuse and misuse. Urinary tract infection (UTI) is consistently the most common infection treated with antibiotics in Australian RACFs. The aim of this article is to provide an overview of how general practitioners (GPs) can support appropriate UTI management in RACFs following antimicrobial stewardship (AMS) principles. GPs are well placed to improve UTI management in RACFs. In this article, criteria for suspected, proven, recurrent and relapsed UTI are outlined, in addition to key AMS practices for the assessment, prevention, treatment and review of UTIs. Included are recommendations for the judicious use of urine dipstick testing, a widespread and longstanding practice in RACFs, and first-line empirical antibiotic prescribing for suspected UTIs. Read the full paper here . Citation: Lim, L. L., & Bennett, N. (2022). Improving management of urinary tract infections in residential aged care facilities. Australian journal of general practice, 51(8), 551-557. DOI: https://doi.org/ 10.31128/AJGP-05-22-6413 .

Opportunities for nurse involvement in surgical antimicrobial stewardship strategies: A qualitative study

by NCAS • 30 Jan, 2022
Opportunities for nurse involvement in surgical antimicrobial stewardship strategies: A qualitative study Courtney Ierano, Arjun Rajkhowa, Fiona Gotterson, Caroline Marshall, Trisha Peel, Darshini Ayton, Karin Thursky Abstract Background Multi-disciplinary antimicrobial stewardship teams are a common strategy employed to optimise antimicrobial prescribing. Nurses play a pivotal role in patient care and safety; however, their role and potential opportunities across surgical antimicrobial stewardship are not well-established. This study aims to highlight health professional perspectives of the nurse's role and relevant opportunities for nurses to engage in and lead surgical antimicrobial stewardship initiatives. Methods An exploratory, multi-site, collective qualitative case study. Transcribed audio-recordings of focus groups with health professionals underwent thematic analysis, with mapping to established frameworks. Results Four key themes were identified; surgical antimicrobial prophylaxis is not prioritised for quality improvement, but nurses perceive benefits from surgical antimicrobial prophylaxis education and training; professional hierarchy hinders nurse engagement and leadership in antimicrobial stewardship; nurses are consistently engaged with patient care throughout the surgical journey; and clarity of roles and accountability for surgical antimicrobial prophylaxis review and follow-up can bolster quality improvement initiatives. Discussion Many opportunities exist for nurse engagement in surgical antimicrobial stewardship. Identification of barriers and enablers support theoretically informed strategies i.e., education and guideline accessibility; multidisciplinary collaborations; executive support for nursing capacity building and the standardisation of surgical antimicrobial prophylaxis workflow and documentation. Conclusions Nurses are critical to patient safety and to supporting antimicrobial stewardship, in the operating theatre, and throughout the patient's surgical journey. Applying theoretical frameworks to understand barriers and enablers to nurses’ contribution to antimicrobial stewardship has given insights to inform interventions to support nurse engagement. Tweetable abstract : Nurses are critical for patient safety. Many opportunities exist to support them as surgical antimicrobial stewards. Read the full paper here . Citation : Ierano, C., Rajkhowa, A., Gotterson, F., Marshall, C., Peel, T., Ayton, D., & Thursky, K. (2022). Opportunities for nurse involvement in surgical antimicrobial stewardship strategies: A qualitative study. International Journal of Nursing Studies, 128, 104186. DOI: https://doi.org/10.1016/j.ijnurstu.2022.104186 .

A systems thinking approach for antimicrobial stewardship in primary care

by NCAS • 30 Dec, 2021
Sajal K. Saha, David C.M. Kong, Danielle Mazza & Karin Thursky Abstract Introduction The establishment of antimicrobial stewardship (AMS) in primary care is central to substantially reduce the antimicrobial use and the associated risk of resistance. This perspective piece highlights the importance of systems thinking to set up and facilitate AMS programs in primary care. Areas covered The challenges that primary care faces to incorporate AMS programmes is multifactorial: an implementation framework, relevant resources, team composition, and system structures remain under-researched, and these issues are often overlooked and/or neglected in most parts of the world. Progress in the field remains slow in developed countries but potentially limited in low- and middle-income countries. Expert opinion The key AMS strategies to optimize antimicrobial use in primary care are increasingly known; however, health system components that impact effective implementation of AMS programs remain unclear. We highlight the importance of systems thinking to identify and understand the resource arrangements, system structures, dynamic system behaviors, and intra- and interprofessional connections to optimally design and implement AMS programs in primary care. An AMS systems thinking systemigram (i.e. a visual representation of overall architecture of a system) could be a useful tool to foster AMS implementation in primary care. Read the full paper here .  Citation : Saha, S. K., Kong, D. C. M., Mazza, D., & Thursky, K. (2022). A systems thinking approach for antimicrobial stewardship in primary care. Expert Review of Anti-Infective Therapy, 20(6), 819-827. DOI: https://doi.org/10.1080/14787210.2022.2023010 .

Consensus guidelines for antifungal stewardship, surveillance and infection prevention, 2021

by NCAS • 22 Dec, 2021
Anna Khanina, Shio Yen Tio, Michelle R. Ananda-Rajah, Sarah E. Kidd, Eloise Williams, Lynette Chee, Karen Urbancic, Karin A. Thursky and Australasian Antifungal Guidelines Steering Committee  Abstract Invasive fungal diseases (IFD) are serious infections associated with high mortality, particularly in immunocompromised patients. The prescribing of antifungal agents to prevent and treat IFD is associated with substantial economic burden on the health system, high rates of adverse drug reactions, significant drug–drug interactions and the emergence of antifungal resistance. As the population at risk of IFD continues to grow due to the increased burden of cancer and related factors, the need for hospitals to employ antifungal stewardship (AFS) programmes and measures to monitor and prevent infection has become increasingly important. These guidelines outline the essential components, key interventions and metrics, which can help guide implementation of an AFS programme in order to optimise antifungal prescribing and IFD management. Specific recommendations are provided for quality processes for the prevention of IFD in the setting of outbreaks, during hospital building works, and in the context of Candida auris infection. Recommendations are detailed for the implementation of IFD surveillance to enhance detection of outbreaks, evaluate infection prevention and prophylaxis interventions and to allow benchmarking between hospitals. Areas in which information is still lacking and further research is required are also highlighted. Read the full paper here . Citation : Khanina, A., Tio, S. Y., Ananda-Rajah, M. R., Kidd, S. E., Williams, E., Chee, L., Urbancic, K., Thursky, K. A., & Australasian Antifungal Guidelines Steering, C. (2021, 2021/11/01). Consensus guidelines for antifungal stewardship, surveillance and infection prevention, 2021. Internal Medicine Journal, 51 (S7), 18-36. DOI: https://doi.org/https://doi.org/10.1111/imj.15586 .

NCAS AAW 2021: AMS in aged care

by NCAS • 22 Nov, 2021
Antimicrobial Awareness Week 2021 - webinar ANTIMICROBIAL STEWARDSHIP IN AGED CARE Chair: A/Prof. Noleen Bennett (NCAS & VICNISS, Melbourne Health) Quality use of antimicrobials in residential aged care services: An update from the Aged Care Quality and Safety Commission Dr. Lyn-li Lim (Aged Care Quality and Safety Commission) Basic principles of antimicrobial use Ms. Xin Fang (NCAS, Melbourne Health) The Royal Commission into Aged Care and the implications for AMS Dr. Janet Sluggett (Registry of Senior Australians, South Australian Health and Medical Research Institute) National Infection Surveillance Program for Aged Care (NISPAC) A/Prof. Leon Worth (VICNISS, Melbourne Health) Preliminary results: Barriers and enablers to the implementation of a national infection and antimicrobial surveillance system Ms. Eliza Watson (NISPAC, Melbourne Health) Recommended resources for IPC and AMS A/Prof. Noleen Bennett (NCAS & VICNISS, Melbourne Health)

NCAS AAW 2021: How to use data

by NCAS • 19 Nov, 2021
Antimicrobial Awareness Week 2021 - webinar HOW TO USE DATA – SUCCESS STORIES, PITFALLS AND OPPORTUNITIES Chair: Prof. Karin Thursky (NCAS, Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne) Optimising audit and feedback: recent evidence from implementation research Prof. Jill Francis (School of Health Sciences, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne) CASE STUDIES How to optimise antimicrobial allergy documentation A/Prof. Jason Trubiano (Austin Hospital, Melbourne) How big is this problem? Quantifying paediatric infections using activity-based management data Dr. Brendan McMullan (Sydney Children's Hospital) An innovative AMS program for children in remote and regional areas: optimising antibiotic use through early intravenous-to-oral conversion Dr. Minyon Avent (State-wide AMS Program, Queensland Health) Repurposing disease surveillance to capture social drivers of AMR Dr. Teresa Wozniak (CSIRO) Applying big data to general practice: implementation of AMS Dr. Brian Hur (NCAS & APCAH, Faculty of Veterinary and Agricultural Sciences, University of Melbourne) Evaluating the implementation of a pilot quality improvement program to support appropriate antimicrobial prescribing in general practice Dr. Ruby Biezen (Department of General Practice & NCAS, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne) Embedding clinical trials in the electronic medical record to improve antibiotic use Dr. Coen Butters (John Hunter Children’s Hospital, Newcastle) Q&A The National Antimicrobial Prescribing Survey and the Clinical Care Standards Dr. Rodney James (NCAS, Melbourne Health), Ms. Xin Fang (NCAS, Melbourne Health) and Ms. Fiona Doukas (Australian Commission on Safety and Quality in Health Care)
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