Welcome to part two of our series on antimicrobial stewardship. Last week we ran a blog called Why antimicrobial resistance matters in aged care, which discussed the findings of the AURA report. This blog is the second part of our two-part series.
The AURA 2021 report
The Commission released its Fourth Australian report on antimicrobial use and resistance in human health (AURA 2021) in August 2021. On reading it, I noted that there are a great number of key messages throughout the report, all excellent points. I decided to focus on two key messages. The first key message was that improper use of antimicrobials can have a devastating impact in the long term, potentially disrupting a variety of medical interventions, from organ transplants to chemotherapy to managing diabetes.
The second point is interesting as it would be good to understand why during 2020, when COVID-19 reared its ugly head, there was a decrease in the use of antimicrobials.
Key message 2
During 2020, in response to COVID-19, Australia experienced substantial decreases (between 22% and 49%) in PBS dispensing for several antimicrobials, including amoxicillin, cefalexin and doxycycline.
AURA 2021 report
In the AURA report it was articulated that the COVID-19 pandemic in 2020 has had a dramatic impact on dispensing rates, an experience that has also been reported in other countries.
This suggests a decrease in dispensing for seasonal respiratory infections, which coincided with pandemic control measures such as hand hygiene, physical distancing and fewer trips to the doctor.
The report suggests that these 2020 results may provide an opportunity to target inappropriate antimicrobial usage (AU) in the community by reducing AU for conditions for which antimicrobials are not generally recommended.
The Commission will work with clinicians, state and territory governments, and the Australian Government to explore strategies to improve appropriateness of prescribing, particularly for upper respiratory tract infections, and sustain infection prevention and control activities.
FOURTH AUSTRALIAN REPORT ON ANTIMICROBIAL USE AND RESISTANCE 2021
Antimicrobials in aged care
The bad news is that in residential aged care, levels of inappropriate antimicrobial use remain high.
The Aged Care National Antimicrobial Prescribing Survey (2019 AC NAPS) results for 2019 were included in the AURA 2021 report. The issues that remain of concern in aged care are as follows:
- Prolonged duration of antimicrobial use
- High rates of prn (as required) prescriptions for antimicrobials
- High rates of topical antimicrobial use, particularly for prn administration
- Prolonged prophylaxis for conditions that are not recommended by guidelines
- Poor documentation of indication, review and stop dates for antimicrobial prescriptions.
To someone who has conducted medication audits these issues are not surprising. In fact, they have been a long-standing issue that reflect on clinical and medical practices.
Analysis of prescriptions reported to the 2019 AC NAPS indicated that:
- Approximately 20% of these prescriptions were for prophylaxis, which is concerning as antimicrobials are rarely recommended for prophylaxis.
- Almost one-third (30.4%) of all prescriptions were for topical antimicrobials, which also accounted for more than 90% of prn prescriptions, most commonly clotrimazole (74.1%). The prn use of clotrimazole may lead to inappropriate duration of therapy, and unnecessary use of antifungals, either topically or systemically, may contribute to the development of resistance.
- Almost one in six (15.0%) antimicrobials were prescribed for prn administration. This may reduce clinical review of antimicrobial choice at time of onset of infection, and decisions regarding duration of treatment, leading to extended duration of treatment.
- There was an improvement in documentation of antimicrobial review or stop dates (64.7%), compared with 58.9% in 2018.
- The most common clinical indications for prescriptions were cystitis; other - skin, soft tissue or mucosal; pneumonia; tinea; and non-surgical wound infections.
The report states that many of these conditions can be prevented by managing hydration and providing good basic hygiene care. Non-pharmacological management is also a key consideration for these conditions.
In conclusion AMS remains a high priority for Australia and globally. As aged care professionals we can play a significant role in reducing the risk of antimicrobial resistance. The AC NAPS results clearly identify that aged care has work to do; we can see this as an opportunity and take the lead in this challenge.
To succeed in this, pharmacists, residents, families, team members and medical practitioners must work together. Communication, education and consistency in practice are essential factors if AMS is to be an effective strategy in reducing the risk of AMR.
I just want to acknowledge that the Commission is not the enemy. They are there to ensure that antimicrobial stewardship is in place to improve the safe and appropriate use of antimicrobials, reduce resident harm, and prevent antimicrobial resistance in Australia.
Food for thought:
- Do you have an AMS working group?
- Is AMS a standard agenda item in your Medication Advisory Committee meetings?
- Do you have an AMS policy?
- How do you, and should you, monitor compliance?
- What are your results telling you?
- Do you have AMS education and training opportunities for staff?
- How do you communicate information to staff and residents?
- Is there an education program for residents and their families?
- How involved is your pharmacist in education and monitoring?
On that note I will sign off. I started these articles thinking that AMR and AMS would be somewhat boring. After some reading and thinking about the current challenges, I find myself somewhat enlightened and interested and hope this also inspires you to read more on AMS/AMR. If you’re a Bug Control member, don’t forget you can log into Bug Control and do a quick training module on AMS Infection Control | Home (talentlms.com).
When I was asked to write about AMS, I thought it time to bring myself up to speed. There is so much information available, but I did speed read a few reports, these are as follows:
- Australian Commission on Safety and Quality in Health Care (the Commission) AURA 2021, the fourth report released on the 27th August 2021 New report on antimicrobial use and resistance in Australia | Australian Commission on Safety and Quality in Health Care
- Aged Care National Antimicrobial Prescribing Survey Report (AC NAPS) Sept 2020 2019 Aged Care National Antimicrobial Prescribing Survey Report (AC NAPS) | Australian Commission on Safety and Quality in Health Care
- Australian Commission on Safety and Quality in Health Care Antimicrobial Stewardship Clinical Care Standards published in 2020 Antimicrobial Stewardship Clinical Care Standard | Australian Commission on Safety and Quality in Health Care
- The Aged Care Quality Standards- specifically Standard 8 released in July 2019. Standard 8. Organisational governance | Aged Care Quality and Safety Commission
Emilia Graham is a quality compliance operations innovation and improvement clinical governance consultant.