Where to from here? Identifying and prioritising future directions for addressing drug-resistant infection in Australia

Background: The Australian National Antimicrobial Resistance Strategy calls for a collaborative effort to change practices that have contributed to the development of drug-resistance and for implementation of new initiatives to reduce antibiotic use. Methods: A facilitated workshop was undertaken at the 2019 National Australian Antimicrobial Resistance Forum to explore the complexity of antimicrobial stewardship (AMS) implementation in Australia and prioritise future action. Participants engaged in rotating rounds of discussion using a world café format addressing six topics relating to AMS implementation. Once all tables had discussed all themes the discussion concluded and notes were summarised. The documents were independently openly coded by two researchers to identify elements relating to the implementation of antimicrobial stewardship. Results: There were 39 participants in the facilitated discussions, including pharmacists, infectious disease physicians, infection prevention nurses, and others. Participants discussed strategies they had found successful, including having a regular presence in clinical areas, adapting messaging and implementation strategies for different disciplines, maintaining positivity, and being patient-focused. Many of the recommendations for the next step involved being patient focussed and outcomesdriven. This involves linking data to practice, using patient stories, using data to celebrate wins and creating incentives. Discussion: Recommendations from the workshop should be included in priority setting for the implementation of AMS initiatives across Australia

Oral or intravenous antibiotics?

Intravenous antibiotics are overused in hospitals. Many infections can be managed with oral antibiotics.Oral antibiotics avoid the adverse effects of intravenous administration. They are also usually less expensive.When intravenous antibiotics are indicated, it may be possible to switch to oral therapy after a short course. There are guidelines to aid the clinician with the timing of the switch so that there is no loss of efficacy.Infections that may be suitable for a short course of intravenous antibiotic include pneumonia, complicated urinary tract infections, certain intra-abdominal infections, Gram-negative bacteraemia, acute exacerbations of chronic lung disease, and skin and soft tissue infections.Bone and joint infections and infective endocarditis are managed with prolonged courses of intravenous antibiotics. However, there is research looking at the feasibility of an earlier switch to oral antibiotics in these conditions

Neonatal chronic lung disease

Chronic lung disease (CLD), formerly known as bronchopulmonary dysplasia, is presently defined as the need for oxygen therapy either at 28 days of age or greater than 36 weeks postmenstrual age. Clinical signs and symptoms include tachypnea, retractions, apnea, and radiographic findings of poorly inflated lungs with reticulogranular opacities. The disease develops as a result of chronic pulmonary inflammation and continuous lung injury induced by oxygen, positive pressure ventilation, and other causes. Fifty to sixty-five percent of neonates with CLD are rehospitalized with respiratory problems, and 21% of very low birth weight neonates are diagnosed with asthma or other respiratory disorders by the age of five. These infants are at risk of adverse neurodevelopmental sequelae as they have a more complicated neonatal course. Many studies have explored various preventive therapies including α-proteinase inhibitors, superoxide dismutase, antioxidants, and ventilatory management. Although the results from these trials are promising, further studies are needed to define which patients are most likely to benefit from preventive therapy. Two preventive treatment approaches that have shown a decrease in morbidity and an improvement in mortality are antenatal steroids and surfactant therapy. Postnatal corticosteroid therapy continues to be the mainstay of treatment for CLD, however, there are a number of detrimental side effects associated with this treatment. Due to the increased incidence in periventricular leukomalacia, early treatment of steroid therapy cannot be recommended. The optimal time to start steroid therapy appears to be after the first week of life. In addition, the lowest dose and shortest duration of treatment needs to be implemented in order to minimize potential complications. Although bronchodilators and diuretics continue to be used extensively in infants with CLD, there are surprisingly few well-controlled studies that have evaluated the clinical impact of this therapy. Further trials are needed in order to support the routine use of these therapies in CLD. Unfortunately, inhaled steroids have not shown an improvement in long-term outcomes of CLD, however, they have shown a decrease in systemic steroid usage. CLD is a complex disease with many unanswered questions. Further studies are needed to evaluate the effects of various treatment modalities with particular focus on the long-term outcomes such as oxygen and ventilator dependency as well as the incidence of CLD

An underutilised resource for Antimicrobial Stewardship: a ‘snapshot’ of the community pharmacists’ role in delayed or ‘wait and see’ antibiotic prescribing

Various strategies have been implemented in primary care to address the inappropriate use of antibiotics, with varying degrees of success. One such intervention is delayed or 'wait and see' prescribing, where the prescriber indicates to wait a few days before dispensing the antibiotic. The aim of this study was to explore community pharmacists' perceptions and practice experiences with delayed antibiotic prescribing.An online survey was advertised in two professional pharmacy organisations' e-newsletters for community and internship pharmacists in Queensland, Australia, from January to April 2016.We received 120 responses. 103 (86%) worked in a community pharmacy. Sixty per cent of the respondents would not dispense the delayed antibiotic prescription if a patient presented to the pharmacy within 24 h of seeing a doctor. Instead, they would advise the patient to wait and fill the prescription if they are not improving.The concept of delayed or a 'wait and see' antibiotic prescription was well received by the participating community pharmacists. These healthcare professionals are well placed to be effective stewards of antibiotics and can play an important role in collaboration with other healthcare professionals to optimise the quality use of antibiotics in primary care

Evaluation of quick sequential organ failure assessment and systemic inflammatory response syndrome in patients with gram negative bloodstream infection

Background: The quick sequential organ failure assessment (qSOFA) score predicts mortality in patients with suspected infection. We sought to understand how well qSOFA and the Systemic Inflammatory Response Syndrome (SIRS) criteria predict gram negative bacteraemia. Methods: We prospectively evaluated 99 patients with gram negative bloodstream infection from a single tertiary centre. We assessed the utility of SIRS and qSOFA for their rate of positivity and association with early delivery of antibiotics

Pharmaceutical reforms: Clinical pharmacy ward service versus a medical team model

Background: The Australian Pharmaceutical Advisory Council's (APAC) Guiding principles to achieve continuity in medication management were developed to advocate the continuum of pharmaceutical care for hospital inpatients. As part of the Australian Health Care Agreements, pharmaceutical reforms that include implementation of the APAC guidelines are underway. Clinical pharmacy services at the Royal Adelaide Hospital do not fully comply with the APAC guidelines. Aim: To assess whether key APAC guiding principles are achievable on a medical ward with one full-time equivalent clinical pharmacist. Method: Two clinical ward pharmacy models were investigated. A clinical pharmacy ward service was compared to a medical team model. Patients admitted to a general medical ward were included in the two phases of the study. In Phase A (4 weeks), the clinical pharmacist serviced a 30-bed medical ward and in Phase B (4 weeks) the same clinical pharmacist serviced the same 30-bed medical ward and also provided an extended hours service in the emergency department. During both phases all patients received a medication history interview, ongoing clinical review and discharge medication counselling. Results: 246 patients were admitted to the general medical ward during the study period - 13 8 in Phase A and 108 in Phase B. 109 (79%) patients were reviewed in Phase A and 83 (77%) patients in Phase B. As a result of the medication history interviews, incorrectly charted medications were amended in 48 (7%) interventions in Phase A and 20 (6%) interventions in Phase B. 207 interventions (Phase A: 129; Phase B: 78) were documented during clinical reviews. Discharge medication counselling was provided to 30 (60%) patients in Phase A and 27 (49%) patients in Phase B. Conclusion: The key APAC guiding principles were partly achievable using the two models investigated. For either model, an increase in staffing resources would be necessary to comply with the APAC guidelines