Antibiotic Awareness Week 2015 Information Bulletin
The Antimicrobial Use and Resistance in Australia (AURA) Project
November 2015
During 2015, the Australian Commission on Safety and Quality in Health Care (the Commission) has been progressing the development of a national surveillance system for antimicrobial use (AU) and antimicrobial resistance (AMR). The Antimicrobial Use and Resistance in Australia (AURA) Surveillance System is integrating existing high-quality data collections on AU and AMR; enhancing a number of these programs to expand coverage to provide in-depth analysis and enhanced jurisdictional and national reporting; and establish new systems as needed, such as an alert system for critical antimicrobial resistances (CARs).
There are a number of surveillance programs which will be integrated under AURA as the national system. These are:
· Australian Group on Antimicrobial Resistance’s (AGAR) collection of resistance data;
· National Antimicrobial Prescribing Survey (NAPS);
· National Antimicrobial Utilisation Surveillance Program (NAUSP); and
· the expansion of Queensland Health’s OrgTRx System to provide a national passive AMR surveillance system.
Structured planning and careful due diligence by the Commission, in partnership with Australia’s leading technical experts, is equipping the AURA Surveillance System with enhanced functionality and capability. Some of the enhancements related to AU data collections include:
· a 64% increase in participation in the 2014 NAPS compared with the 2013 NAPS, providing improved representativeness of survey results and robustness of national data on AU appropriateness;
· the expansion of NAPS into residential aged care facilities (acNAPS) in June 2015 saw 186 residential aged care facilities participating in a pilot acNAPS to improve understanding of aged care AU;
· increased reporting and capability of the NAUSP in 2014 and 2015, resulting in 90% of principal referral hospital beds, and 82% of total beds in hospitals with more than 50 beds represented, improving the utility and accessibility of data for local quality improvement and national analysis; and
· access to Pharmaceutical Benefits Scheme data, to increase surveillance opportunities for AU in the community sector.
The Commission has also been enhancing and expanding AMR surveillance by:
· expanding the OrgTRx passive surveillance system for AMR as the basis for a national system. ACT and the private sector in Queensland are currently underway, with OrgTRx expansion into NSW and Victoria in development;
· enhancing the AGAR collections on identified and emerging resistant organisms; and
· developing a National Alert System for Critical Antimicrobial Resistances, to provide formalised national surveillance and timely advice to the jurisdictions on the presence of critical antimicrobial resistances in Australia.
This bulletin provides more detail on the key collections under the AURA Surveillance System for AU.
The National Antimicrobial Prescribing Survey (NAPS)
Since 2013, the National Centre for Antimicrobial Stewardship (NCAS) have developed and implemented the National Antimicrobial Prescribing Survey (NAPS) involving a suite of standardised antimicrobial prescribing surveys to assist healthcare facilities assess the quality of their antimicrobial prescribing practices. The NAPS has two primary aims:
1. Develop a practical, electronic audit tool to assist healthcare facilities monitor their antimicrobial prescribing practices and facilitate local quality improvement; and
2. Provide aggregate local and national data which can be utilised to identify areas for improvement and inform guidelines and educational content.
Hospital-based NAPS
Now in its third year, the hospital-based NAPS has continued to have strong uptake with 248 hospitals participating in the 2014 survey. The findings from these surveys has contributed substantially to the understanding of AU within Australian hospitals and identified several target areas for improvement including high rates of inappropriate prescribing for surgical prophylaxis and common respiratory infections such as infective exacerbation of COPD, infective exacerbation of asthma and bronchitis. Key findings of the 2014 hospital-based NAPS include the following:
· Around 25% of prescriptions were non-compliant with guidelines, and 23% deemed inappropriate.
· More than 40% of surgical prophylaxis prescriptions were considered inappropriate, mainly due to incorrect duration and dose, and absence of indication.
· Almost 36% of surgical prophylaxis prescriptions were continued beyond 24 hours.
The 2015 survey is currently underway with results due to be released by mid-2016. The 2014 NAPS Report is available for download from the Commission’s website: www.safetyandquality.gov.au.
Pilot of the Aged Care NAPS
In 2015, NCAS in collaboration with Guidance AMS and the Australian Infection Surveillance - Aged Care (AIS-AC) developed, implemented and evaluated the pilot acNAPS. The primary aim of the pilot acNAPS was to develop a tool for use in residential aged care facilities (RACFs) that would assist in monitoring antimicrobial prescribing practices, microbiologic testing and infections.
186 RACFs from varying areas of remoteness, across 6 states collected data on a single day between June 22nd and August 31st 2015. There were no participants from the Australian Capital Territory or the Northern Territory.
The data from the pilot indicates there is significant scope for improvement in preventing infections and improving the quality of antimicrobial prescribing in Australian RACFs.
Key findings included the following:
· 5% of residents had a suspected or confirmed infection on the audit day. The majority of these were respiratory, urinary and skin infections.
· 11% of residents were receiving an antimicrobial on the audit day.
· Of the 975 prescriptions, 32% did not have the reason for the antimicrobial documented and 65% did not have a review or stop date documented.
· 31% of all prescriptions had been prescribed for greater than 6 months. Of these, only 2% had a review or stop date documented.
· Approximately 1 in 5 prescriptions were for residents who had no signs or symptoms of infection in the 1 week prior to the start date.
Feedback from participants indicated willingness to participate in 2016, and satisfaction with the amount of information required to be collected. Further awareness prior to the 2016 acNAPS commencement date will include educating potential participants about the usefulness of acNAPS, streamlining data collection tools and website enhancement and design.
For further information, please email or phone (03) 9342 9333.
National Antimicrobial Utilisation Surveillance Program (NAUSP)
The National Antimicrobial Utilisation Surveillance Program (NAUSP) is a passive surveillance system which monitors rates of AU in hospitals to provide data to inform strategies to prevent and contain AMR. Prudent antimicrobial prescribing is essential for reducing the emergence of widespread AMR resistance in pathogens.
NAUSP commenced in July 2004 and is managed by the Infection Control Service, Communicable Disease Control Branch, SA Health. NAUSP provides contributing hospitals with bimonthly and annual reports on their antibiotic usage rates, enabling them to compare their usage to similarly peered hospitals to facilitate the identification of areas for quality improvement.
Since 2008, all Australian states and territories have been represented in NAUSP, with hospital participation doubling since the introduction of the National Safety and Quality Health Service Standards in 2011.
NAUSP reports provide rich data on AU patterns which can be used to develop effective and enhanced antimicrobial stewardship strategies. Key findings of the Antimicrobial use in Australian Hospitals: 2014 report of the National Antimicrobial Utilisation Surveillance Program include the following:
· 20 agents accounted for 92% of all antibacterials used in Australian hospitals (on a defined daily dose basis) with six antibacterials representing more than 50%. These included amoxicillin with clavulanic acid, flucloxacillin and cephazolin.
· In 2014, the total rate for antibacterials prescribed in Australia decreased by 2.2% from 2013, which is a decrease of 6.2% from Australia’s peak usage in 2010.
· Usage rates varied widely between hospitals, with a high of 2040 and a low of 330 defined daily doses per 1000 occupied bed days. Some of this variation can be attributed to variations in complexity of care provided in different hospitals.
The 2014 NAUSP report is available for download from the Commission’s website: www.safetyandquality.gov.au
Pharmaceutical Benefit Scheme Data - AU in the community
The Pharmaceutical Benefits Scheme (PBS) collects data on medicines that are dispensed within the community. These are largely medicines prescribed through general practice, outpatient services and Aboriginal Medical Services.
PBS data can provide valuable information about prescriptions for antimicrobials dispensed across Australia, including a breakdown of the volume, type and location. The Commission is currently working with the Department of Health to access and analyse PBS data to identify patterns and trends in AU within the community, and to compare those trends with patterns of AU in other sectors.
An initial review of this data, as well as data from the other AURA core collections, will be included in the First National Report on AU and AMR in Human Health. This publication is currently under development and due for release in 2016.
Further information on the AURA Surveillance System can be found at: www.safetyandquality.gov.au
National Alert System for Critical Antimicrobial Resistances (NASCAR)
A key component of the AURA Surveillance System will be the National Alert System for Critical Antimicrobial Resistances (NASCAR). NASCAR is proposed as an efficient and responsive system to enable critical antimicrobial resistances (CARs) to be confirmed and information provided in a timely way to clinicians, technical experts, and health system managers, so that effective infection control strategies can be enacted.
CARs are defined as resistance mechanisms known to be a serious threat to last line antimicrobial agents. They constitute a small group of high impact organisms that can result in significant morbidity in hospitals, including Enterobacteriaceae and Staphylococcus aureus.
Whilst some data for CARs are captured through existing state-based surveillance programs, there is currently no formalised system for the identification and timely communication of information concerning suspected outbreaks of CARs at the state or territory levels.
The establishment of NASCAR will develop a nationally coordinated AU and AMR surveillance system capable of measuring the burden of AMR and AU, monitoring trends and measuring the effects of interventions over time. NASCAR will utilise current laboratory testing processes, and will coordinate the transfer of the confirmatory information through the AURA Surveillance System. NASCAR will commence operation by the end of 2015 and is expected to be fully operational by May 2016.
NASCAR will provide the mechanism for strengthened preventative infection control, coordinated and structured containment action at affected hospitals, and timely local, jurisdictional and national level response implementation across the health system.