The National Centre for

Antimicrobial Stewardship

Professor Karin Thursky, MBBS, BSc, FRACP, MDDirector, National Centre for Antimicrobial Stewardship, RMH at the DohertyDepartment of Medicine, Uni MelbSir Peter MacCallum Department of Oncology, Uni MelbDeputy Director, Department of Infectious Diseases, Peter MacCallum Cancer Centre

Twitter: @NCAS_AusNCAS Website: https://ncas-australia.org

NHMRC Health Services Research CREA One Health Program: 6 streamsTertiary hospitalsRural and regional hospitalsAged care General Practice Companion veterinary medicineLivestock

Policy roleNational AMR Implementation Plan (30 items)AURA Program Partner (NAPS)Commission AMS AdvisoryASTAG

ActivitiesNAPS, ACNAPs, SNAPS, Vet surveillanceComputerised tools for AMS (Guidance)Education and mentorshipEmerging regional role/ WHO

ID physiciansGPsPharmacistsNursesBioethicistMicrobiologistVetsDevelopers

Our research questions:

How are antibiotics being used?

Volume, indication, appropriate AND inappropriate use

What are the drivers? Prescriber knowledge and attitudes

What interventions fit workflow and are acceptable?

What interventions are effective and sustainable to change

prescribing behaviour?

What can we learn from each stream?

Can we ultimately change practice and policy?

National Antimicrobial Prescribing Survey (NAPS)

SNAPS 2016 Pilot

42% Private Hospitals

SNAPS 2016 Pilot

SNAPS 2016 Pilot

Peri-Procedural ProphylaxisReasons for inappropriateness, by peri-operative antimicrobial doses

Post-Procedural Prophylaxis

Post-Procedural Prophylaxis

Rural and regional NAPS data 2014-2016

No audits

No prescriptions

Major city 248 31,579

Inner regional

194 9,652

Outer regional

116 5,035

Remote 22 1,068

Very remote 16 522

Point prevalence national audit(period prevalence in small sites until 30 prescriptions)

City Inner regional

Outer regional

Remote and very Remote

CAP 10.6% CAP 18.6% CAP 20.1% CAP 16.3%

Surg Px 9.7% Surg Px 8.1% Cellulitis 7.5% Cellulitis 12.3%

UTI 5.5% UTI 7.1% COPD 6.3% UTI 5.0%

Sepsis empiric 4.0%

Cellulitis 6.9% UTI 6.0%

HAP 3.6% COPD 5.3%

NAPS data from Australian regional hospitals

Prosthetic joint infection -Bacterial 31.09%

Sepsis (all types) 28.46%

Endocarditis - all types 27.68%Febrile neutropenia -Bacterial 23.30%

% of antimicrobial orders for high risk conditions that were in

rural hospitals

Bishop 2017

Inappropriate orders regional & remote versus major city

Sepsis: directed therapy-gram positive bacteraemia 12.6% (28/223) & 6.5% (38/591), p=0.004

Sepsis: empiric therapy -organism unknown 26.0% (139/535) & 12.0%(150/1252), p<0.0001

Current models for rural/regional

• Statewide support (Queensland)

• Parent Hospital model (NSW networks)

• Single local expert (Albury)

• Telehealth support AMS rounds (Shepparton)

• Visiting Physician AMS rounds (Latrobe)

• Pharmacist led model but need support

• Nurse led model

• Phone support only (ad hoc)

Local person needs

help/support

The Expert they call needs to know their facility, their

capabilities, to take responsibility and follow up

“You just need a good pharmacist and an expert for them to call when they need help”

Hospital AMS recommendations are evolving• Approval process is still important

– Move to mandatory approvals at many sites

• Post prescription review required

– Without it, AMS is incomplete (and less effective)

• Evaluating performance of the AMS service

– Team needs to review activity, interventions

• Providing meaningful feedback – clinicians & management

– Comparisons valuable

• Models of AMS in rural/regional hospitals and in private hospital still evolving

• Models of AMS in EMM sites evolving (NSW in particular)

Tamma PD, et al. What Is the More Effective Antibiotic Stewardship Intervention: Preprescription Authorization or Postprescription Review With Feedback? ClinInfect Dis. 2017 Mar

Davey P, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev. 2017 Feb

The role of computerised decision

support in antibiotic prescribing

The Prescriber

Infections cognitively difficult to treat

Pressures to use knowledge

Facilitates access to best practice

Standardises practice

Minimises errors

The AMS Program

Improved productivity

Efficiently monitor prescribing

patterns and behaviours

Triage patients for review

Supports key elements of AMS

(restriction, approvals, alerts)

Data aggregation, reporting

Pathology

Microbiology

Pharmacy Electronic

Medical Record

Electronic

Medication

ManagementBackend/Infec

tion

surveillance

software

Antimicrobial

approval

systems

Mobile

applications

Formulary

Restricted indications

Guidelines/decision support

Post-prescription review

Surveillance

Audit and feedback

AMR alerts

Infection alerts (e.g., C. diff)

Bug-drug mismatches

HAI/AMR Surveillance

Alerts

Order sets

Drug interactions

Restrictions

Indications

Triggers (e.g., sepsis)

Care templates

(Advanced decision support)

Radiology

Access to guidelines

Calculators

Systems below may have

mobile compatible view

The Guidance Workflow

Impact of Guidance AMS program

• 70 hospitals Australia wide (including EMR sites)

• Cost savings in drug expenditure

• Reduction in targeted restricted antibiotics

• Reduction in hospital acquired infection/ C. Diff

• No unintended consequences

• Recognised as an exemplar in hospital accreditation

Thompson, ASA 2013, Bond JAC 2017, Buising et al, JAC 2008, Cairns et al MJA 2013 , Yong et al, JAC 2010

Epworth Hospital(Private)

Captures all dispensed drugs as pharmacy alerts in GuidanceTarget PPR (includes unrestricted)

SheppartonBase(Public, regional)

Local approval system

PPR

Telehealthservice from

VIDS

Onsite pharmacist, weekly AMS rounds via Telehealth, monthly visits

Ramsay Albury(Private, regional)

Onsite AMS pharmacistNurse led approvals “feel empowered”Escalate to AMS clinician (non-ID)** Need programmatic support from experts

1/3 of antimicrobials prescribed with no

signs or symptoms in the week prior

52% of residents did not meet infection criteria (McGeer)

22% of antimicrobials had been prescribed

for > 6 months

Review or stop date not documented for 49% of

antimicrobials

Current NCAS research projects• Qualitative study looking a the role of nurses in end of life care• Interventional study looking at the impact of Resp PCR on antibiotic use• Deep dive into ACNAPs data : UTIs

June 19th-Sep 1st point prevalence survey293 Aged Care Homes 12,344 permanent, respite or transitional care residents were reviewed.

General Practice THE key target

In 2015, 30.5 million antibiotics

dispensed (PBS / RPBS)

• 44.7% Australian population

≥ 1 antimicrobial dispensed

• 27% had a broad-spectrum

antibiotic

• Increase in use of systemic

antibiotics by 6.7% over 2014

(measured by defined daily

dosage)Australian Commission on Safety and Quality in Health Care. AURA 2017: second Australian report on antimicrobial use and resistance in human health. Sydney: ACSQHC; 2017.

• Prescribing behaviors• No current AMS standards in

GP accreditation framework (due October 2017)

• GP prescribing systems link poorly to guidelines

• Indication is not mandatory• Repeat scripts/delayed

prescribing

MAGNET database (44 GP practices, Melbourne Inner East)

Cephalexin

Data courtesy of Lesley Hawes, NCAS PhD Fellow, Monash Dep GP

NCAS Activities

• GP-NAPS Pilot project

• TG Foundation/RACGP Grant

• Qualitative study looking at drivers

• Qualitative study understanding access to guidelines and prescribing information – Opportunities for decision support at the point of

care (only 22% prescriptions have an indication!)

• The role of community pharmacists in AMS

Veterinary stream (companion animals)

• Investigated the rate of antimicrobial exposure in a cohort of companion animals

• First national survey of surgical Px in companion animals, cattle and horses

(n=889)

– antimicrobial usage

– compliance with guidelines (where possible)

– need for additional guidelines and antimicrobial stewardship

• Qualitative study of enablers to, and barriers of, antimicrobial stewardship in

veterinary practices

• Developed an antimicrobial stewardship package for Australian veterinary practices

– Plan for interventional trialPhD: Laura HardefeldtPost Doc: Kirsten Bailey

Survey of surgical prophylaxis

https://doi.org/10.1016/j.vetmic.2017.03.027

AVJ: In Process

JVIM: Under review

Rate of antimicrobial use

1,919,382 pet insurance claims 2013-2017 (cats and dogs)

531,018 involved prescription of antimicrobials

611,788 antimicrobial agents prescribed

Critically important antimicrobials

0

5

10

15

20

25

30

35

Cats Dogs Cats Dogs Cats Dogs Cats Dogs

2013 2014 2015 2016

Pro

po

rtio

n o

f to

tal

anti

mic

rob

ials

(%

)

Cefovecin Enrofloxacin Other fluoroquinolones

An injectable 3rd generation cephalosporin. Single dose lasts 2 weeks.

Cats: Abscess, wounds, dermatitis, UTIDogs: Dermatits, non-infectious orthopaedic disease, wounds

Centre Manager: Dr Arjun Rajkhowa

Chief Investigators

• Prof Karin Thursky – Director

• A/Prof Kirsty Buising – Deputy Director

• Prof Glenn Browning (Animal Lead)(FVAS)

• Prof Danielle Mazza (GP lead) (Monash)

• Dr Trisha Peel (Tertiary Lead)

• Prof Michael Richards (VIDS/VICNISS)

• A/Prof Rhonda Stuart (Aged Care Lead)

• A/Prof David Kong (Monash)

• A/Prof Caroline Marshall (VIDS)

Associate Investigators

• Dr N. Deborah Friedman (Barwon Health)

• Dr Helen Billman-Jacobe (Animal)(FVAS)

• Dr Tom Schulz (VIDS)

• Ms Evette Buono (NSW CEC)

• Dr Noleen Bennett (VICNISS/Guidance)

• Prof Frank Dunshea (Animal)(FVAS)

• A/Prof Leon Worth (VICNISS)

Paediatric advisors

• Dr Brendan McMullan (NSW)

• Dr Celia Cooper (SA)

VICNISS

• Dr Ann Bull

• Ms Sandra Johnson

Guidance (NAPS)

• Dr Rodney James – Clinical operations

• Ms Caroline Chen/Robyn Ingram – NAPS Project Manager

• Ms Sonia Koning – Project Officer

• Ms Ngan-Ha Tran- Implementation

• Ms Renukadevi Padhamanaban –Director IT (and team)

• Dr Steve Christov- Business operations

PhDs & Post Docs

• Dr Laura Hardefeldt (PhD) - Animal

• Ms Leslie Dowson (PhD) – Aged Care

• Ms Jaclyn Baker (PhD) – Rural

• Ms Courtney Ierano (PhD) - Tertiary

• Dr Kirsten Bailey (Post doc) - Animal

• Ms Lesley Hawes– General Practice

• Ms Fiona Gotterson – Nursing

• Ms Helen Crabb (Post doc)- Livestock

• Karen Urbancic – Antifungal stewardship

Australian Commission on Safety and Quality in Health Care

(AURA/NAPS/AMS)

• Kathy Meleady,Prof John Turnidge, Prof Marilyn Cruikshank

University of Melbourne Faculty of General Practice

• Prof Jane Gunn, Dr Jo-anne Manski-Nankervis Doug Boyle

GP NAPS Project Officer

• Ruby Beizen