National Antimicrobial Prescribing Survey Research Articles

The quality of antimicrobial prescribing in skin and soft tissue management in Australian hospitals: an analysis of the National Antimicrobial Prescribing Survey data

Skin and soft tissue infections (SSTIs) are among the most common indications for antimicrobial prescribing in hospitals. Inappropriate antimicrobial use can lead to increased morbidity, unnecessary hospital re-admission and increased antimicrobial resistance. This study aimed to assess the quality of antimicrobial prescribing practices in SSTI management within Australian hospitals to provide guidance for future practice. A retrospective analysis was conducted with data from the National Antimicrobial Prescribing Survey (NAPS). SSTI prescribing data from Hospital NAPS (2013-2022) and surgical site infection data from Surgical NAPS (2016-2022) datasets were analysed. Variables assessed included guideline compliance, appropriateness as per the structured NAPS algorithm, and reasons for inappropriateness. From the Hospital NAPS dataset, 40,535 antimicrobial prescriptions for SSTIs were analysed. The most common indication was cellulitis (34.1%, N=13,822), and the most prescribed antimicrobial was flucloxacillin (18.8%, N=7,638). SSTI indications had a lower rate of guideline compliance but a higher rate of appropriateness compared with all other indications for antimicrobial prescriptions (guideline compliance 66.3%, N=21,035 vs 67.4%, N=156,285; appropriateness 75.6%, N=30,639 vs 72.7%, N=209,383). The most common reason for inappropriateness was incorrect dose or frequency (29.3%, N=2367). From the Surgical NAPS dataset, 5674 prescriptions for surgical site infections were analysed. Of these, 68.2% (N=3867) were deemed to be appropriate. The most common reason for inappropriateness was incorrect dose or frequency (27.7%, N=350). As SSTIs are a common indication for prescribing an antimicrobial in Australian hospitals, identifying effective antimicrobial stewardship strategies to optimize antimicrobial use for SSTI management is recommended to improve patient outcomes.

Cultivating global antimicrobial stewardship: linguistic and cultural validation of the Australian National Antimicrobial Prescribing Survey appropriateness assessment definitions for Portugal.

Antimicrobial resistance is driven by inappropriate antimicrobial prescribing. The National Antimicrobial Prescribing Survey (NAPS) is an Australian-developed auditing platform to assist in the assessments of antimicrobial quality by antimicrobial stewardship programmes using consensus-based definitions. The NAPS has demonstrated to be transferable to other countries. Its adaptation to Portugal could improve knowledge about the quality of antimicrobial prescribing in the country. To translate, culturally adapt, and validate the Australian Hospital NAPS appropriateness assessment definitions of antimicrobial prescribing for Portugal. International recommendations on translation and adaptation of instruments were followed. Two panels of experts participated in the process, using Zoom® for discussions and interviews, and Google Forms® for assessing vignettes. A native English-speaking person proficient in Portuguese conducted the back-translation. SPSS v.28 and Excel® were used for validity calculation. The Portuguese version was well accepted, its implementation being perceived as desirable and feasible by the experts. Validation process showed a Fleiss' κ score of 0.483 (95% CI, 0.415-0.551, P < 0.005) for appropriateness, and an average agreement with the Australian NAPS team of 0.8 and 0.9, respectively, for appropriateness and reasons for inappropriateness. The Portuguese version of the Australian Hospital NAPS appropriateness assessment definitions of antimicrobial prescribing, the first to be translated from English, was deemed non-inferior to the original, was well accepted, considered to be desirable and feasible, and could inspire other countries, particularly other Portuguese-speaking countries, to adapt and validate them in their own contexts, reinforcing the possibility of transferring NAPS use beyond Australia.

Appropriateness of antimicrobial prescribing for oral and dental conditions in Australian hospitals: 2013 to 2022

ObjectivesDentists manage a variety of oral infections in clinical practice. Inappropriate antimicrobial prescribing by dentists occurs frequently and antimicrobial stewardship strategies should include dentistry. The aim of this retrospective analysis of the Australian Hospital National Antimicrobial Prescribing Survey (Hospital NAPS) dataset, was to describe the types of oral and dental indications where antimicrobials were prescribed, and assess the guideline compliance and appropriateness of the antimicrobials in Australian hospitals. MethodsData from the Hospital NAPS was extracted for oral and dental indications from 2013 to 2022. The types of oral and dental indications presented, and the corresponding antimicrobials prescribed were assessed for compliance according to national prescribing guidelines, and appropriateness according to the NAPS structured algorithm. ResultsA total of 8,001 prescriptions for 7,477 patients were identified, from 433 hospitals. Antifungal, antibiotic and antiviral agents accounted for 84.5 %, 15.4 % and 0.03 % of prescriptions respectively. A greater proportion of antibiotics were prescribed in regional and rural areas compared to antifungals. The prescriptions assessed as compliant were 80.0 % and 44.7 % of antifungals and antibiotics respectively. Prescriptions assessed as appropriate were 84.4 % of antifungals, and 65.3 % of antibiotic prescriptions. ConclusionsA wide variety of antimicrobials were used with moderate levels of compliance and appropriateness. Future interventions should include targeted education, utilisation of prescribing guidelines, and tools to diagnose and manage oral and dental conditions. Consideration can be given to adjustment of the Hospital NAPS tool to cater for oral conditions and include the provision of dental treatment in the management of these infections. Clinical significanceA wide variety of oral and dental conditions are presented in Australian hospital settings, managed by a range of antibiotics and antifungals, with moderate levels of compliance to guidelines and appropriateness. Antimicrobial stewardship strategies should target and support dentistry in hospital settings.

Assessment of antimicrobial prescribing patterns, guidelines compliance, and appropriateness of antimicrobial prescribing in surgical-practice units: point prevalence survey in Malaysian teaching hospitals.

Objectives: This study sought to investigate the quality of antimicrobial prescribing among adult surgical inpatients besides exploring the determinants of non-compliance and inappropriate prescribing to inform stewardship activities. Methods: A cross-sectional point prevalence study employing Hospital National Antimicrobial Prescribing Survey (Hospital NAPS) was conducted in April 2019 at two teaching hospitals in Malaysia. Results: Among 566 surgical inpatients, 44.2% were receiving at least one antimicrobial, for a total of 339 prescriptions. Antimicrobials belonging to the World Health Organization's Watch group were observed in 57.8% of cases. Both hospitals exhibited similar types of antimicrobial treatments prescribed and administration routes. A significant difference in antimicrobial choice was observed between hospitals (p < 0.001). Hospital with electronic prescribing demonstrated better documentation practice (p < 0.001). Guidelines compliance, 32.8% (p = 0.952) and appropriateness, 55.2% (p = 0.561) did not significantly differ. The major contributors of inappropriateness were incorrect duration, (15%) and unnecessary broad-spectrum coverage, (15.6%). Non-compliance and inappropriate prescribing were found to be 2 to 4 times significantly higher with antimicrobial prophylaxis prescription compared to empirical therapy. Conclusion: Antimicrobial stewardship efforts to improve appropriate surgical prescribing are essential. These initiatives should prioritize surgical prophylaxis prescribing, focusing on reducing unnecessarily prolonged use and broad-spectrum antimicrobials, raising awareness among prescribers and promoting proper documentation.

Antimicrobial use and appropriateness in neutropenic fever: a study of the Hospital National Antimicrobial Prescribing Survey data.

Neutropenic fever (NF) is a common complication in patients receiving chemotherapy. Judicious antimicrobial use is paramount to minimize morbidity and mortality and to avoid antimicrobial-related harms. To use an Australian national dataset of antimicrobial prescriptions for the treatment of NF to describe antimicrobial use, prescription guideline compliance and appropriateness; and to compare these findings across different healthcare settings and patient demographics. We also aimed to identify trends and practice changes over time. Data were extracted from the Hospital National Antimicrobial Prescribing Survey (Hospital NAPS) database from August 2013 to May 2022. Antimicrobial prescriptions with a NF indication were analysed for antimicrobial use, guideline compliance and appropriateness according to the Hospital NAPS methodology. Demographic factors, hospital classifications and disease characteristics were compared. A total of 2887 (n = 2441 adults, n = 441 paediatric) NF prescriptions from 254 health facilities were included. Piperacillin-tazobactam was the most prescribed antimicrobial. Overall, 87.4% of prescriptions were appropriate. Piperacillin-tazobactam and cefepime had the highest appropriateness though incorrect piperacillin-tazobactam dosing was observed. Lower appropriateness was identified for meropenem, vancomycin, and gentamicin prescribing particularly in the private hospital and paediatric cohorts. The most common reasons for inappropriate prescribing were spectrum too broad, incorrect dosing or frequency, and incorrect duration. This study provides insights into antimicrobial prescribing practices for NF in Australia. We have identified three key areas for improvement: piperacillin-tazobactam dosing, paediatric NF prescribing and private hospital NF prescribing. Findings from this study will inform the updated Australian and New Zealand consensus guidelines for the management of neutropenic fever in patients with cancer.

Documenting the indication for antimicrobial prescribing: A retrospective observational study of long-term care homes.

Overuse of antimicrobials in residents of long-term care homes is common and can result in harm. Antimicrobial stewardship interventions are needed in the long-term care (LTC) homes setting to improve the appropriate use of antimicrobials. Previous literature has highlighted the importance of documenting antimicrobial indication as a strategy that contributes to improve antimicrobial use; however, there is a lack of evidence in LTC homes. This study examines the prevalence, clarity, and facility-level variability of antibiotic indication documentation in this setting. This is an observational retrospective study of oral antibiotic prescriptions dispensed to 218 homes between January 1, 2021 and December 31, 2022 in Ontario, Canada. Indication was obtained from reviewing antibiotic prescription data. Clarity was determined by comparing documented indication to the National Antimicrobial Prescribing Survey (NAPS). Descriptive analysis was performed to examine the prevalence and clarity of indication documentation. Funnel plots were generated to examine variability in prevalence of indication documentation and clarity at the home level. Overall, 22.9% (7998/34,867) of prescriptions had an indication documented. The proportion of indications that were clear was 37% (2984/7998). The most common indications were for urinary (45%), skin and soft tissue (19.9%) and respiratory infections (15.0%). At the home level, the median prevalence of indication was 19.6% (interquartile range [IQR]: 10.8%-31.4%) and median prevalence of clear indications was 35.1% (IQR: 23.8%-42.9%). Funnel plots revealed substantial variability in indication prevalence with 46.3% of homes falling outside of 99% limits but minimal variability in indication clarity between homes with only 8.7% of homes outside of 99% control limits. There is an opportunity to increase both the prevalence and clarity of antibiotic prescriptions in LTC homes. Future work should focus on determining how best to support prescription indication documentation in this setting with consideration being given to prescription workflow and most common antibiotic prescription indications.

Appropriateness of antibiotic prescribing for patients with sepsis in rural hospital emergency departments.

This was a multicentre retrospective cohort study of adult patients (≥18 years) presenting with a process associated International Classification of Diseases code (ICD-AM-10) pertaining to sepsis between January 2017 and July 2020 to rural Emergency Departments. Our primary outcome was antibiotic appropriateness as defined by the Australian Therapeutic Guidelines (for antibiotic selection relative to infecting source) and the National Antimicrobial Prescribing Survey tool. Our secondary outcome was in-hospital mortality. Relevant clinical and non-clinical, physiological and laboratory data were collected retrospectively. Multivariate logistic regression was used to estimate the odds of both inappropriate antibiotic prescribing and in-hospital mortality based on clinical and non-clinical factors. A total of 378 patients were included who primarily presented with sepsis of unknown origin (36.8%), a genitourinary (22.22%) or respiratory (18.78%) source. Antibiotics were appropriately prescribed in 59% of patients. A positive Quick Sequential Organ Failure Assessment score (qSOFA) (odds ratio [OR] = 0.49; 95% confidence interval [CI], 0.29-0.83), a respiratory infection source (OR = 0.5; 95% CI, 0.29-0.86) and documented allergy (OR = 0.42; 95% CI, 0.25-0.72) were associated with a lower risk of appropriate prescribing in multivariate analysis. Forty-one percent of patients received antibiotics within 1 h of presentation. Inappropriate antibiotic prescribing was not associated with in-hospital mortality. The rates of appropriate antibiotic prescribing in rural Emergency Departments for patients presenting with sepsis is low, but comparable to other referral metropolitan centres.

1017. Impact of a Multifaceted Approach to Audit-and-Feedback Antimicrobial Stewardship Intervention in Acute Leukemia Patients Using Measures of Appropriateness

Abstract Background Prospective audit-and-feedback (PAF) for hospitalized leukemia patients is resource-intensive, while data on stadardized assessment of the quality, i.e. appropriateness, of antimicrobial prescribing are scarce. We implemented a multifaceted program combining patient-level PAF with unit-level appropriateness reports generated by serial point-prevalence surveys using the web-based Canadian National Antimicrobial Prescribing Survey (NAPSTM) platform. Quality of prescribing was assessed based on local guidelines and clinical justification using published definitions (Fig. 1). The objective of the study was to evaluate the impact of PAF+NAPS interventions on antibiotic use (AU) in acute leukemia patients at an academic cancer center, compared to PAF-only. Methods In this retrospective cohort study, during the PAF-only period (Jun 1 2017-May 31 2019), the AMS team led 30-minute PAF rounds with prescribers 2x/week. After implementating PAF+NAPS (Jun 1 2019-Mar 31 2020), we met 2x/month for 30 minutes. At each meeting we presented an automated NAPS dashboard report (Fig. 2) of aggregate appropriateness adjudication of antibiotic prescriptions, followed by targeted PAF on select patients with complex antimicrobial needs. We analyzed the impact of the two-step approach on the primary outcome of AU (defined daily dose [DDD]/100 patient-days [PD]) using interrupted time series models. Secondary outcomes were appropriateness of AU during PAF+NAPS, lenght of stay and in-hospital mortality. Target appropriatenesss was at least 90%. Categorical variables were compared using chi-square test and continuous variable using Mann Whitney U test.Fig. 2Sample Canadian NAPS Dashboard Report From a Point-Prevalence Survey Results Patient characteristics and outcomes were presented in Table 1. AU data were presented in Table 2. AU of piperacillin-tazobactam and vancomycin decreased significantly after implementation of 2x/month PAF+NAPS, compared to 2x/week PAF-only interventions (Fig. 3). Overall appropriateness was 91.4% (1757/1921 prescriptions). Conclusion Despite reducing frequency of interventions from 2x/week to 2x/month, PAF+NAPS was an efficient and sustainable AMS model that promoted appropriate and judicious antimicrobial use in hematology-oncology patients (Fig. 4), allowing the AMS team to expand to other specialized areas. Disclosures Shahid Husain, MD, Astellas: Grant/Research Support|Avir: Grant/Research Support|F2G: Grant/Research Support|Gilead: Grant/Research Support|Merck: Grant/Research Support|Pfizer: Grant/Research Support|Pulmocide: Grant/Research Support|Synexis: Grant/Research Support|Takeda: Honoraria

Metronidazole prescribing practices in Australian hospitals: Measuring guideline compliance and appropriateness to support antimicrobial stewardship

BackgroundMetronidazole is a commonly prescribed antimicrobial in Australian hospitals. Inappropriate use may increase risks to patient care, such as toxicities and antimicrobial resistance. To date, there is limited information on the quality of metronidazole prescriptions to inform antimicrobial stewardship and quality improvement initiatives. This study aims to describe the quality of metronidazole prescribing practices in Australian hospitals. MethodsRetrospective data analysis of the Hospital National Antimicrobial Prescribing Survey (Hospital NAPS). Data were collected by auditors at each participating hospital using a standardised auditing tool. All data from 2013 to 2021 were de-identified and analysed descriptively. Variables included were antimicrobial prescribed, indication, guideline compliance and appropriateness. ResultsMetronidazole was the fifth most prescribed antimicrobial in the Hospital NAPS dataset (2013–2021), accounting for 5.7 % (n = 14,197) of all antimicrobial prescriptions (n = 250,863). The proportion of metronidazole prescriptions declined by 2 % from 2013 to 2021 (p < 0.001). The most common indications were surgical prophylaxis (15.3 %), diverticulitis (9.4 %), aspiration pneumonia (7.3 %). Over half (53.5 %) of metronidazole prescriptions were deemed compliant with prescribing guidelines and 67.8 % were deemed appropriate. These rates were comparatively lower than the overall results of all antimicrobials. The primary documented reason for inappropriateness was that the spectrum was too broad (34.2 %). Surgical prophylaxis had the lowest rates of guideline compliance (53.8 %) and appropriateness (54.3 %). ConclusionsMetronidazole remains widely used in Australian hospitals with suboptimal rates of guideline compliance and appropriateness. A noted area for improvement that we identified was using metronidazole when its spectrum was too broad, possibly when anaerobic therapy is unnecessary. With increasing international adoption of the Hospital NAPS programme, future comparative studies will be critical to identify global trends of antimicrobial prescribing quality. Antimicrobial stewardship (AMS) programmes have proven to be effective in improving prescribing quality and should be considered to specifically target improvements in metronidazole prescribing.

Antibiotic use and quality indicators of antibiotic prescription in Bhutan: a point prevalence survey using the Australian National Antimicrobial Prescribing Survey tool.

The National Action Plan on Antimicrobial Resistance in Bhutan promotes the rational use of antibiotics. It is important to establish baseline data on the use of antibiotics and the quality indicators of antibiotic prescriptions to identify where improvement efforts may need to be focused. To describe the prevalence and patterns of antibiotic prescription and establish baseline data regarding quality indicators of antibiotic prescriptions in four major hospitals in Bhutan. This was a point prevalence survey of antibiotic use among inpatients in June 2022 conducted using the Australian National Antibiotic Prescribing Survey (NAPS). There were 314 patients (41.5%) receiving at least one antibiotic on the audit day. Among prescriptions reviewed, 278 (88.5%) had indications for use documented, 102 (32.5%) had a review or stop date documented and 120 (38.2%) had microbiology samples collected prior to antibiotics. Ceftriaxone (68; 21.7%), cefazolin (41; 13.1%) and metronidazole (32; 10.2%), were the common antibiotics prescribed. The most common indications for use were surgical prophylaxis (42; 13.4%), community-acquired pneumonia (39; 12.4%) and sepsis (26; 8.3%). There were 125 prescriptions (39.8%) that were compliant with national/therapeutic antibiotic guidelines and 169 (53.8%) where antibiotic prescriptions were appropriate. This study identified key areas for targeted interventions in antimicrobial stewardship programmes in Bhutan. The prevalence of antibiotic use, indications for use, and drug choices were similar to data from other countries. Documentation plans for durations of use, prolonged surgical prophylaxis and concordance of choices with guideline recommendations present opportunities for improvement.

P33 Using the Australian National Antimicrobial Prescribing Survey (NAPS) portal to undertake an annual point prevalence survey (PPS)

Abstract Background Annual point prevalence surveys (PPS) are cornerstones in antimicrobial stewardship (AMS). The National Antimicrobial Prescribing Survey (NAPS) is a web-based qualitative auditing platform that provides a standardized and validated tool to assist hospitals in assessing the appropriateness of antimicrobial prescribing. Objectives To evaluate the usefulness of NAPS in a UK tertiary hospital setting. Methods Permission to use the platform was given by NAPS on a pilot basis. NAPS e-learning was completed by the AMS team. All patients on antimicrobials on a single day were extracted using the Cerner electronic prescribing system. Indication, appropriateness and compliance to guidelines were reviewed, anonymized and uploaded by the trained individuals to NAPS. Ethical approval was not required. Results 695 patients were audited. 35% (n = 241) of the patients were prescribed antimicrobials. The total number of antimicrobial prescriptions was 326, and 46% (n = 190) of antimicrobial prescriptions were under general medicine and geratology. The most common indications for antimicrobials were respiratory 27% (n = 87) followed by intra-abdominal infection 11% (n = 37), sepsis and bacteraemia 11% (n = 37), urinary tract infection 10% (n = 34) and skin and soft tissue infection 8% (n = 25). The most prescribed agent was co-amoxiclav 34% (n = 111). Compliance with guidelines was achieved in 84% (n = 273) of prescriptions, and 72% (n = 236) were deemed appropriate. Inappropriate prescriptions were more prevalent for co-amoxiclav (38%) and ceftriaxone (43%) compared with amoxicillin (6%) and doxycycline (8%) (Figure 1). The most common reasons for inappropriate prescription were incorrect (prolonged) duration (44%) and spectrum too broad (28%). Conclusions Using NAPS, we identified that general medicine and geratology are the major users of antimicrobials, and pneumonia is the leading indication for prescribing. Co-amoxiclav is the main antibiotic prescribed, and appropriateness of this and other antibiotics, such as ceftriaxone, are below the 90% target. Consequently, targeted AMS efforts can be designed. PPS results are feedback to the respective teams and have been used in teaching sessions to encourage teams to take ownership of their data and influence prescribing patterns. We have found NAPS to be user friendly and reliable. Reports are produced immediately on completion of the survey to allow timely feedback. We would recommend NAPS as a useful tool in performing PPS and as a potential way to benchmark NHS trusts.

P36 Using the Australian National Antimicrobial Prescribing Survey portal (NAPS) to benchmark antibiotic prescribing within an Integrated Care Board (ICB): a pilot point prevalence survey (PPS) of two NHS Trusts

Abstract Background PPS is useful in evaluating volume and appropriateness of antimicrobial prescribing to guide specific antimicrobial stewardship (AMS) interventions. Integrated care systems enable collaboration within an ICB and benchmarking of antimicrobial prescribing in constituent trusts to identify disparities and learn from sharing best practice. NAPS is a web-based qualitative auditing platform which is used to conduct an annual Australia-wide PPS. To assess the suitability of NAPS in benchmarking antimicrobial prescribing practices, we piloted the NAPS platform in the acute admission ward areas in two NHS Trusts within an ICB. Methods In OUHFT, admissions to 2 acute medicine wards on a single day were extracted using the Cerner electronic prescribing system. Antimicrobial prescriptions were anonymized, reviewed using NAPS protocol and uploaded to the NAPS platform. In BHT, antimicrobial prescriptions on 2 admission wards were collected manually using the NAPS parameters and audit standards and entered directly into Excel®. Ethical approval was not required due to the anonymized nature of this audit. Results A total of 124 patients at OUHFT and 53 patients at BHT were included. The proportion of patients prescribed antimicrobials varied, with a prevalence of 23% (n = 29) at OUHFT and 54% (n = 28) at BHT. The total number of antimicrobial prescriptions was approximately 40 per trust. Compliance with guidelines for OUHFT and BHT (88% versus 83%) and stewardship appropriateness (73% versus 80%) were similar. The main indication for antimicrobials was pneumonia. The most common reasons for inappropriateness were ‘incorrect duration’ and ‘spectrum too broad’. The most prescribed antimicrobials differed, with co-amoxiclav and amoxicillin (43%) at OUHFT and metronidazole and clarithromycin (24%) at BHT. Non-compliance with guidelines was frequently associated with the use of doxycycline and co-amoxiclav (47%) at OUHFT and amoxicillin and piperacillin/tazobactam (72%) at BHT. Conclusions Benchmarking of antimicrobial prescribing was possible as both PPSs were conducted using the NAPS parameters and standards. Focusing efforts on antibiotic prescribing for pneumonia, the use of broad-spectrum antimicrobials and reducing duration of courses will be taken forward as a key focus for AMS efforts. NAPS is a suitable tool for benchmarking, sharing best practice and facilitating discussion of AMS interventions across an ICB. This model should be considered as a template for national benchmarking of antimicrobial prescribing.

Validation of the Antifungal National Antimicrobial Prescribing Survey (AF-NAPS) quality assessment tool.

The Antifungal National Antimicrobial Prescribing Survey (AF-NAPS) was developed to undertake streamlined quality audits of antifungal prescribing. The validity and reliability of such tools is not characterized. To assess the validity and reliability of the AF-NAPS quality assessment tool. Case vignettes describing antifungal prescribing were prepared. A steering group was assembled to determine gold-standard classifications for appropriateness and guideline compliance. Infectious diseases physicians, antimicrobial stewardship (AMS) and specialist pharmacists undertook a survey to classify appropriateness and guideline compliance of prescriptions utilizing the AF-NAPS tool. Validity was measured as accuracy, sensitivity and specificity compared with gold standard. Inter-rater reliability was measured using Fleiss' kappa statistics. Assessors' responses and comments were thematically analysed to determine reasons for incorrect classification. Twenty-eight clinicians assessed 59 antifungal prescriptions. Overall accuracy of appropriateness assessment was 77.0% (sensitivity 85.3%, specificity 68.0%). Highest accuracy was seen amongst specialist (81%) and AMS pharmacists (79%). Prescriptions with lowest accuracy were in the haematology setting (69%), use of echinocandins (73%), mould-active azoles (75%) and for prophylaxis (71%). Inter-rater reliability was fair overall (0.3906), with moderate reliability amongst specialist pharmacists (0.5304). Barriers to accurate classification were incorrect use of the appropriateness matrix, knowledge gaps and lack of guidelines for some indications. The AF-NAPS is a valid tool, assisting assessors to correctly classify appropriate prescriptions more accurately than inappropriate prescriptions. Specialist and AMS pharmacists had similar performance, providing confidence that both can undertake AF-NAPS audits to a high standard. Identified reasons for incorrect classification will be targeted in the online tool and educational materials.

Time to embrace sepsis pathways and antibiotic prescribing decision support in the emergency department: Observations from a retrospective single site clinical audit.

To compare clinician documentation of sepsis for infective presentations in the ED against a formal sepsis pathway in the ED and to assess appropriateness of the initial parenteral antibiotic prescription for adult patients in ED. A retrospective, clinical audit of adult patients who received at least one parenteral antibiotic in ED over a 10-week period in 2018. Documented initial clinical impression was compared with an approved sepsis pathway. Antibiotic appropriateness was assessed using National Antimicrobial Prescribing Survey definitions. Assessment was carried out by an infectious diseases pharmacist, with input from an infectious diseases physician. Two hundred and nineteen infective presentations were included in the analysis. There was a discordance between the initial documented clinical impression compared with the classification when a sepsis pathway was applied. An initial documented clinical impression of sepsis and septic shock was present in 38 (60.3%) of the presentations compared to 63 presentations when a formal sepsis pathway was applied as a screening tool. There was a significant difference in the proportion of patients in each diagnostic group (infection, sepsis and septic shock) according to documented clinical impression versus sepsis pathway classification (P = 0.0002). There were 386 prescriptions for antibiotics as part of the initial management. Antibiotic appropriateness for the initial prescription was assessed as 63.7% appropriate, 27.2% inappropriate and 9.1% not assessable. Our observations demonstrate that use of a formal sepsis pathway may improve the screening and early diagnosis of sepsis and septic shock and that there is a need for antibiotic prescribing guidance in the ED.

Comparing the appropriateness of antimicrobial prescribing among medical patients in two tertiary hospitals in Malaysia.

Malaysia is an upper-middle-income country with national antimicrobial stewardship programs in place. However, hospitals in this country are faced with a high incidence of multidrug-resistant organisms and high usage of broad-spectrum antibiotics. Therefore, this study aimed to use a standardized audit tool to assess clinical appropriateness, guideline compliance, and prescribing patterns of antimicrobial use among medical patients in two tertiary hospitals in Malaysia to benchmark practice. A prospective hospital-wide point prevalence survey was carried out by a multidisciplinary team in April 2019 at the University Malaya Medical Centre (UMMC) and the Hospital Canselor Tuanku Muhriz (HCTM), Kuala Lumpur, Malaysia. Data was collected from the patient's electronic medical records and recorded using the Hospital National Antimicrobial Prescribing Survey toolkit developed by the National Centre for Antimicrobial Stewardship, Australia. The appropriateness of prescriptions was 60.1% (UMMC) and 67% (HCTM), with no significant difference between the two hospitals. Compliance with guidelines was 60.0% (UMMC) and 61.5% (HCTM). Amoxicillin-clavulanic acid was the most commonly prescribed antimicrobial (UMMC = 16.9%; HCTM = 11.9%). The appropriateness of antimicrobial prescribing in medical wards, compliance with guidelines, and prescribing patterns were similar between the two hospitals in Malaysia. The survey identified several areas of prescribing that would need targeted AMS interventions.

Auditing tools for antimicrobial prescribing in solid organ transplant recipients: The why, the how, and an assessment of current options.

Antimicrobial stewardship (AMS) aims to optimize antimicrobial use. Auditing and reporting of antimicrobial prescribing are essential. Auditing tools for solid organ transplant (SOT) patients should tailor to their needs. We reviewed published data describing auditing tools in the general and SOT population. We focused on three internationally or nationally available auditing tools. The National Antimicrobial Prescribing Survey (NAPS) is web-based tool to report antimicrobial consumption and assess appropriateness using standardized definitions based on consensus guidelines. In the absence of guidelines, adjudication is based on AMS principles. An automated dashboard, analyses by indication or antimicrobial, and benchmarking reports are available. The National Healthcare Safety Network Antimicrobial Use/Resistance module was developed by the Centers for Disease Control and Prevention for hospitals to upload monthly data, which are standardized for benchmarking. It does not assess appropriateness or address SOT wards. The Global-Point Prevalence Survey from bioMérieux collects data on antimicrobial regimen, indication and microbial resistance. Variables unique to SOT include comorbidities and devices. Assessment of appropriateness is limited to guideline adherence, and benchmarking may require prearrangement with bioMérieux. Benchmarking requires prearrangement. Advances in electronic health record systems and clinical decision support tools can improve the efficiency of the auditing process. Each AMS auditing tool has unique features for SOT patients. Capturing immunosuppression, source control, organ dysfunction, donor-derived infection, serology, and colonization status will enhance their applicability.

Prophylactic Antimicrobial Prescribing in Australian Residential Aged-Care Facilities: Improvement is Required.

Inappropriate antimicrobial use can lead to adverse consequences, including antimicrobial resistance. The objective of our study was to describe patterns of prophylactic antimicrobial prescribing in Australian residential aged-care facilities and thereby provide insight into antimicrobial stewardship strategies that might be required. Annual point prevalence data submitted by participating residential aged-care facilities as part of the Aged Care National Antimicrobial Prescribing Survey between 2016 and 2020 were extracted. All antimicrobials except anti-virals were counted; methenamine hippurate was classified as an antibacterial agent. The overall prevalence of residents prescribed one or more prophylactic antimicrobial on the survey day was 3.7% (n = 4643, 95% confidence interval 3.6-3.8). Of all prescribed antimicrobials (n = 15,831), 27.1% (n = 4871) were for prophylactic use. Of these prophylactic antimicrobials, 87.8% were anti-bacterials and 11.4% antifungals; most frequently, cefalexin (28.7%), methenamine hippurate (20.1%) and clotrimazole (8.8%). When compared with prescribing of all antimicrobial agents, prophylactic antimicrobials were less commonly prescribed for pro re nata administration (7.0% vs 20.3%) and more commonly prescribed greater than 6 months (52.9% vs 34.1%). The indication and review or stop date was less frequently documented (67.5% vs 73.8% and 20.9% vs 40.7%, respectively). The most common body system for which a prophylactic antimicrobial was prescribed was the urinary tract (54.3%). Of all urinary tract indications (n = 2575), about two thirds (n = 1681, 65.3%) were for cystitis and 10.6% were for asymptomatic bacteriuria. Our results clearly identified immediate antimicrobial stewardship strategies that aim to improve prophylactic antimicrobial prescribing in Australian residential-aged care facilities are required.

Ophthalmic Antimicrobial Prescribing in Australian Healthcare Facilities.

The National Antimicrobial Prescribing Survey (NAPS) is a web-based, standardized tool, widely adopted in Australian healthcare facilities to assess the reasons for, the quantity of, and the quality of antimicrobial prescribing. It consists of multiple modules tailored towards the needs of a variety of healthcare facilities. Data regarding ophthalmological antimicrobial use from Hospital NAPS, Surgical NAPS, and Aged Care NAPS were analysed. In Hospital NAPS, the most common reasons for inappropriate prescribing were incorrect dose or frequency and incorrect duration. Prolonged duration was also common in Aged Care prescribing: about one quarter of all antimicrobials had been prescribed for greater than 6 months. All three modules found chloramphenicol to be the most prescribed antimicrobial with a high rate of inappropriate prescribing, usually for conjunctivitis.

A Point Prevalence Survey of Antimicrobial Usage in New Brunswick Hospitals.

Prevalence surveys are useful tools for assessing the appropriateness of antimicrobial therapy. The primary objective was to assess patterns of antimicrobial utilization and appropriateness in New Brunswick hospitals. The secondary objective was to assess the impact of hospital size and the presence of a penicillin allergy label on antimicrobial appropriateness. A point prevalence survey was conducted of inpatients taking 1 or more systemic antimicrobials during admission to hospitals in New Brunswick. A structured protocol and web-based data collection tool (National Antimicrobial Prescribing Survey) were used for this survey. Data regarding hospital size and presence of a penicillin allergy label were also collected. Antimicrobial utilization was assessed in terms of guideline compliance and appropriateness. Results were summarized descriptively. A χ2 analysis was performed to describe secondary outcomes. Ten hospitals participated, and a total of 2200 patients were admitted at the time of the survey. The overall prevalence of antimicrobial use was 22.7% (500/2200). A total of 648 antimicrobials were ordered. The most frequently prescribed antimicrobials by class were first-generation cephalosporins (14.0%, 91/648), third-generation cephalosporins (11.3%, 73/648), and piperacillin-tazobactam (10.2%, 66/648). The most common indications for antimicrobial therapy were respiratory tract infections (27.3%, 177/648), urinary tract infections (12.2%, 79/648), and intra-abdominal infections (11.4%, 74/648). Compliance with local or regional treatment guidelines, where applicable, was 66.2% (188/284). Provincially, 68.1% (441/648) of the antimicrobial orders were deemed appropriate. Larger centres had substantially higher rates of appropriateness (p < 0.001). The presence of a penicillin allergy label had no impact on appropriateness (p = 0.21). Several opportunities for targeted interventions were identified to improve antimicrobial prescribing, including decreasing the use of broad-spectrum antimicrobials, increasing guideline compliance, and ensuring documentation of antimicrobial duration by prescribers.

The feasibility and generalizability of assessing the appropriateness of antimicrobial prescribing in hospitals: a review of the Australian National Antimicrobial Prescribing Survey.

The National Antimicrobial Prescribing Survey (NAPS) is a web-based qualitative auditing platform that provides a standardized and validated tool to assist hospitals in assessing the appropriateness of antimicrobial prescribing practices. Since its release in 2013, the NAPS has been adopted by all hospital types within Australia, including public and private facilities, and supports them in meeting the national standards for accreditation. Hospitals can generate real-time reports to assist with local antimicrobial stewardship (AMS) activities and interventions. De-identified aggregate data from the NAPS are also submitted to the Antimicrobial Use and Resistance in Australia surveillance system, for national reporting purposes, and to strengthen national AMS strategies. With the successful implementation of the programme within Australia, the NAPS has now been adopted by countries with both well-resourced and resource-limited healthcare systems. We provide here a narrative review describing the experience of users utilizing the NAPS programme in Canada, Malaysia and Bhutan. We highlight the key barriers and facilitators to implementation and demonstrate that the NAPS methodology is feasible, generalizable and translatable to various settings and able to assist in initiatives to optimize the use of antimicrobials.