Implementation Science and Antimicrobial Stewardship

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 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 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

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 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 .

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 .

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 .

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)