AMR reduces the number of effective antimicrobials available, which increases the morbidity and mortality of infections caused by multidrug-resistant organisms. This has driven demand for effective antimicrobial stewardship (AMS) programs to minimise unnecessary antibiotic use.
For this article, we interviewed Dr Natali Jokanovic, Clinical Trial Coordinator at the Department of Infectious Diseases at The Alfred Hospital and Monash University, to explore Australia’s latest efforts in antimicrobial stewardship in aged care.
Why antimicrobial resistance hits aged care hard
Aged care residents are particularly vulnerable to infections because they are often frail, have multiple medical conditions and weaker immune systems.
High antimicrobial use in aged care homes elevates the risk of antimicrobial-resistant infections for all residents, not just those receiving antimicrobial therapy. In these communal environments, infections spread rapidly via shared living spaces and high-touch surfaces.
Despite a national decline in community antibiotic use, prescription rates among Australians aged 65 and older — particularly those in residential aged care — remain high.
The Antimicrobial Use in the Community: 2023 Report shows antimicrobial use increased by over 11% from 2022 to 2023, and almost three-quarters of aged care home residents received at least one antimicrobial prescription in 2023.
Challenges of implementing antimicrobial stewardship in aged care
While AMS is essential in all healthcare settings to improve infection control practices and reduce inappropriate antimicrobial use, implementing effective programs in aged care homes presents unique and complex challenges.
Dr Jokanovic shared her insights from the recently completed START trial and described an innovative grant project that has recently commenced.
Staffing barriers can undermine antimicrobial stewardship success
Staff in aged care homes are committed to delivering safe, high-quality health care, yet systemic barriers hinder consistent infection prevention and AMS efforts. According to Dr Jokanovic, workforce challenges and imbalances pose a significant challenge for AMS.
In most aged care homes, registered and enrolled nurses, who have greater knowledge of infections and infection control processes, are in the minority. This means the people most involved in the day-to-day care of residents may not always be equipped to identify the early or subtle signs of infection.
“Over 70% of the aged care workforce is made up of personal care workers, who may not have the same level of AMS and infection control training,” Dr Jokanovic explains. “They often come from culturally and linguistically diverse backgrounds (CALD), have varying levels of education and are typically a casual workforce with high turnover. That makes implementing consistent AMS and infection management strategies difficult.”
Having someone on-site who can review medications regularly and advise on adjusting or stopping antibiotics when they’re not needed is a game-changer.
Adding to this is the limited on-site medical presence of doctors. An aged care facility might have several GPs, so one resident might have a different GP from the person in the next room. A GP who prescribes an antimicrobial for an infection may not see a resident in person or may be a locum GP, which impacts continuity of care for residents to monitor antimicrobial use.
Until recently, pharmacists weren’t embedded in aged care facilities, with the government funding a new aged care pharmacist model. Having someone on-site who can review medications regularly and advise on adjusting or stopping antibiotics when they’re not needed is a game-changer.
Dr Jokanovic believes that pharmacists will play a critical role in the future of aged care AMS: “Previously, pharmacists were providing Residential Medication Management Reviews — on admission and thereafter when clinically needed, such as after a hospital stay. We didn’t have the regular, collaborative AMS approach you’d see in a hospital with a dedicated team of onsite doctors, pharmacists and infection specialists.”
Vulnerability of residents complicates antimicrobial stewardship and infection control
Compounding the staffing issues is the aged care resident population itself. Residents have increasingly complex, multiple medical conditions, are often frail and have high rates of cognitive impairment.
About 70% of residents have moderate to severe dementia, and many have communication challenges. This makes recognising infection symptoms harder, and when staff aren’t sure, they might prescribe antibiotics ‘just in case’ or because they are under pressure from residents or their families.
Lessons from the START trial: rethinking antibiotic use
The START trial, supported by the Medical Research Future Fund, explored best-practice antibiotic use. It utilised an education-based, nurse-led AMS program.
Led by Professor Anton Peleg of Monash University, with Dr Jokanovic as Project Coordinator, START involved 12 Victorian aged care homes over 16 months. The trial delivered tailored education (eLearning modules, presentations and fact sheets) and guidelines for assessing and managing common infections for nurses, personal care workers, GPs, pharmacists, residents and families.
START emphasised pausing before prescribing, encouraging staff to consider alternatives before attributing symptoms to infections. For example, urine colour or smell and behavioural changes are commonly misattributed to UTIs, when dehydration or other factors may be the cause.
“Engaging GPs who weren’t on-site was hard. Getting buy-in from multiple stakeholders — nurses, personal care workers, pharmacists, families — was critical. Education had to be tailored and practical,” says Dr Jokanovic.
Despite COVID lockdown challenges during the trial, START yielded important insights, which will be published soon.
OPTICS in RACH: a co-designed future for antimicrobial stewardship and infection prevention and control
Building on results from the START trial, Professor Peleg has received National Health and Medical Research Council funding for a new research project, ‘OPTICS in RACH’, to develop and evaluate an aged care-specific infection prevention and control (IPC) model.
This initiative will include adapting hospital-grade infection control guidelines to the aged care context, education and AMS strategies.
OPTICS in RACH involves a highly engaged co-design process with people with lived experience and end users to enable a highly tailored approach. The co-design process with residents, carers, families and staff will also allow real-world applicability.
The project will have a number of stages, with the intervention rolled out in a trial across 14 residential aged care homes in Victoria.
“It’s early days, but we’re keeping what we’ve learned in mind—targeted, realistic education, simple tools for identifying infections in residents with cognitive impairment, and better collaboration across disciplines,” says Dr Jokanovic.
She hopes the lessons from START will shape more scalable, sustainable AMS models in aged care: “You can’t just lift a hospital AMS program and drop it into aged care. It needs to be tailored — and it needs to work with the realities on the ground.”
Looking ahead: the future of antimicrobial resistance in aged care
Aged care providers play a vital role in Australia’s response to antimicrobial resistance. Programs like START and OPTICS in RACH demonstrate how tailored, evidence-based AMS and IPC strategies can protect residents, preserve antibiotics and ultimately save lives.
Melissa Waine swapped Petri dishes for prose, transforming her love of science into compelling health and medical writing. She is passionate about antimicrobial resistance (AMR) and communicating the looming threat it will pose if we exhaust our supply of effective treatments.
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