Curbing inappropriate antimicrobial use in children

NCAS • Nov 24, 2019

Brendan McMullan, Arjun Rajkhowa and Karin Thursky


(Published in Medical Journal of Australia-Insight)


Antibiotic use in Australia has been found to be highest in children in the 0–9 years age group and in adults in the over 65 years age group. International studies have indicated that inappropriate antimicrobial use in children may be common.


Australia is internationally unique in that it collects information about the prevalence and quality of antimicrobial use across acute care settings nationally, and has access to nationally aggregated data.


The National Antimicrobial Prescribing Survey (NAPS) is an online antimicrobial prescribing auditing program that has been available in Australia since 2013. Public reports on the nationally aggregated results of these audits have been published annually since 2014, but, until recently, no specific analysis of prescribing for children was included in these reports.


In a recent study, we reviewed information on antibiotic prescribing for children from Hospital NAPS audits undertaken across Australia from 2014 to 2017, which covered public and private, and major city, regional and remote hospitals.


How good is antibiotic prescribing for children in Australian hospitals?


Among over 6000 antibiotic prescriptions for children in 253 hospitals, almost 20% of prescriptions were assessed as inappropriate. Appropriateness assessments take into account a range of factors such as antimicrobial choice, timing of administration, dose, duration and others. More than half of surgical antimicrobial prophylaxis prescriptions were assessed as inappropriate. Risk factors for inappropriate prescribing included being admitted outside a specialist children’s hospital or being admitted in a rural or regional hospital.


An indication for antimicrobial use was documented in 79% (4903/6219) of prescriptions; the most frequent indications included empiric therapy for sepsis (586, 9.4% of prescriptions) and antifungal prophylaxis (571, 9.4% of prescriptions, mainly in immunocompromised children and neonates). The agents that were most commonly used for antifungal prophylaxis were oral nystatin, followed by trimethoprim-sulfamethoxazole and then the azole antifungal agents. These were generally used appropriately.


In contrast, prescriptions for surgical antimicrobial prophylaxis were assessed as appropriate in 41% of cases. Surgical prophylaxis prescriptions were assessed as inappropriate often because of incorrect duration of use (generally prolonged use). In 8% (38/459) of surgical prophylaxis prescriptions, the agent selected was assessed as inappropriate (in most cases, a broad-spectrum agent was selected when it was unnecessary).


For another common indication, community-acquired pneumonia, 25% of prescriptions were assessed as inappropriate, mainly because of inappropriate agent selection (19%; 73/378). Appropriateness also varied by antimicrobial class; for example, antiviral use was assessed as appropriate in over 95% of cases, whereas carbapenem use was assessed as appropriate in 60% of cases.


There was also less use of Therapeutic Guidelines: Antibiotic for children admitted to hospital compared with adults, perhaps reflecting a lack of specific information for children and newborns until an update in June 2019.


In primary care, audit tools to measure appropriateness do not exist. National data show a high proportion of antibiotic prescriptions for young children by global standards: in 2016–17, there were over 3 million antibiotic prescriptions for children (a per capita rate far higher than countries such as the Netherlands and Norway). The prescribing was highly variable. Children in the highest prescribing area received antibiotics 16.5 times more than those in the lowest prescribing area. A Victorian study conducted from 2010 to 2014 showed one in five individual children was prescribed an antibiotic each year, and noted an inconsistency between prescribing practice and Therapeutic Guidelines: Antibiotic recommendations.


Antimicrobial stewardship and meeting standards of care


Antimicrobial stewardship (AMS) encompasses a range of strategies and programs that can improve prescribing and limit the spread of antibiotic resistance. Since 2013, all Australian hospitals have been required to meet AMS criteria within the National Safety and Quality Health Service Standards, which require services to provide access to guidelines and review prescribing practice in their facilities. An updated version of Therapeutic Guidelines: Antibiotic was published in June 2019, and included more detailed recommendations for antimicrobial use in children and newborns. Hospitals also have access to the Hospital and Surgical NAPS, which can help monitor and improve antimicrobial prescribing. Undertaking quality audits can enhance AMS activities.


There are currently no national standards that specifically include AMS in general practice. GPs must also pay to access Therapeutic Guidelines. The product information for antibiotics contained in MIMS, which can be accessed more easily, may not be up-to-date.


We don’t have much information about the quality of prescribing in general practice. The Aged Care NAPS module was developed (and has been undertaken nationally since 2015) to improve prescribing in aged care homes, and a module for general practice was piloted in 2017–18. However, at present, we don’t have a nationally available audit tool to measure and improve prescribing for Australian children seen in primary care.


Room for improvement


We have an obligation to provide children with the best possible care. The consequences of unnecessary medication use in children can be significant. Clearly, there is room to improve antibiotic care for children. Health care providers must act together with the community to better promote and support high quality antibiotic prescribing for children.

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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