Professor Thursky is the Director of the National Centre for Antimicrobial Stewardship based at the University of Melbourne, and has directly influenced the implementation of the National AMR Strategy.
Although Australia’s antimicrobial stewardship is far from perfect, compared to many other countries we are doing quite well, and have accreditation programs in place that are driving adoption. In some areas, we’re in fact probably leading the world, particularly with the sophistication of antimicrobial stewardship (AMS) programs in hospitals.
We have a high-quality, universal health care system that is among the best in the world. Per capita, we have high numbers of infectious-disease physicians and advanced practice pharmacists to support stewardship programs in hospitals.
In some ways, being a slightly later adopter of electronic medical records is probably a good thing, because we had established several structures and processes to support stewardship when digital records were started, and these have remained core to AMS programs.
But there are still a host of things we can do to shore up our antimicrobial stewardship.
1. Optimising antimicrobial use
Much of Australia’s AMR funding is currently channelled into infection surveillance. While that’s an important strategy, implementation of actions to optimise antimicrobial use is essential. Simply measuring what infections are present, or the volume of antimicrobials prescribed, is no longer helpful because it tells you nothing about appropriateness.
We need to wholeheartedly pursue our current strategy of applying an appropriate assessment of all antimicrobials to allow meaningful audit and feedback.
2. Increasing education
Excellent educational tools about AMR (and optimal antimicrobial prescribing) are missing at almost all levels of education – primary, secondary, tertiary and post grad. It’s a major gap in Australia. The UK’s Health Security Agency developed the website e-bug, which is a wonderful web-based platform that is being used in primary and secondary schools to educate children about AMR and the appropriate use of antimicrobials. It would be great to start education early.
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Even if prescribers use antimicrobials as judiciously as possible, we can’t stop AMR occurring because it’s a natural phenomenon.
3. Don’t unfairly target the prescribers of antibiotics
Don’t unfairly target the prescribers of antibiotics. They are working within a moral discordance because even if they know prescribing a particular antibiotic might be a problem, at the end of the day, they still need to treat the patient in front of them. Often they will prescribe an antibiotic for particular reasons that might deviate from a guideline – for example, some antibiotic mixtures taste nice and are the only way to get children to take them.
In reality, even if prescribers use antimicrobials as judiciously as possible, we can’t stop AMR occurring because it’s a natural phenomenon in bacteria. It will always happen. We need to conserve how we use antimicrobials as best as possible, which is where stewardship fits in.
Educating the public around these issues, perhaps with well-communicated consumer standards, could take the blame off prescribers and help patients understand that walking out with a script for an antibiotic may not always be the best way forward.
4. Incentivisation strategies
For the implementation of quality systems in healthcare there needs to be a reimbursement, or some sort of financial incentivisation, for hospitals, primary care and aged care to be able to fund quality improvement activities. In other countries, such as Japan, hospitals are given an incentive to put stewardship programs in place.
5. Real-time data
We need to apply the Applied Learning Health System framework to AMR stewardship. This means undertaking real-time interrogation of data and implementation of knowledge gained in rapid, quality-improvement cycles, to ultimately improve patient outcomes.
The data needs to generate sufficient knowledge that can actually drive practice improvement. I always break things down into: What are the structural interventions that need to be happening? What are the process measures that we need to be collecting? What are the outcome measures that we’re going to be collecting? And then, the fourth piece, which is not done very often, is what is actually feasible in the short, medium and long term?
6. Bring the right people to the table
Lastly, we haven’t had the right people at the table. Microbiologists and even people like me are not the ones that are going to make the necessary changes to shore up our antimicrobial stewardship. We need to have social scientists, behavioural-change experts, implementation experts, human-factor experts and digital-health experts.
These are the people who have been largely missing from the discussion around what sort of system we’re going to build to have the best possible stewardship to counter AMR.
Professor Karin Thursky is the director of the National Centre for Antimicrobial Stewardship (NCAS) (based at the University of Melbourne), which is taking a ‘one health’ approach to improving antimicrobial use across all human and animal health sectors; clinical director of the Guidance Group at the Royal Melbourne Hospital at the Doherty; Associate Director of Health Services Research and Implementation Science at the Peter MacCallum Cancer Centre and principal fellow in the Department of Medicine at the University of Melbourne and the Sir Peter MacCallum Department of Oncology.
