AntimicrobialPrescribing Practice in Australia: results of the 2013
National AntimicrobialPrescribingSurvey
November2014
© Commonwealth of Australia 2014
This work is copyright. It may be reproduced in whole or in part for study or training purposes subject to the inclusion of an acknowledgment of the source. Requests and inquiries concerning reproduction and rights for purposes other than those indicated above require the written permission of the Australian Commission on Safety and Quality in Health Care, GPO Box 5480, Sydney, NSW 2001 or
This publication is part of the work being conducted by the Australian Commission on Safety and Quality in Health Care to establish a nationally coordinated antimicrobial resistance and antibiotic usage surveillance system. The work is being undertaken through the Antimicrobial Usage and Resistance in Australia (AURA) project.
ISBN 978-1-921983-44-8 (print), 978-1-921983-95-5 (online)
Suggested citation
Australian Commission on Safety and Quality in Health Care (2014).Antimicrobial prescribing practice in Australia: results of the 2013 National Antimicrobial Prescribing Survey, ACSQHC, Sydney.
Antimicrobial prescribing practice in Australia: results of the 2013 National Antimicrobial Prescribing Surveyand support materials are available on the Commission website at
Contents
Executive summary
Background
The 2013 NAPS
Methods
Survey types
Auditors
Key data fields
General findings
Participating hospitals
Types of surveys performed
Types of auditors
Specific findings on prescribing practices
Most commonly prescribed antimicrobials
Documentation of indication
Most common indications
Key indicators
Appropriateness of prescribing
Overall appropriateness
Appropriateness of assessable prescriptions
Appropriateness of prescriptions for prophylaxis
Appropriateness of top 20 prescribed antimicrobials
Appropriateness by top 20 indications
Indications most commonly assessed to be appropriate
Overall reasons for inappropriateness
Compliance with guidelines
All prescriptions
Assessable prescriptions
Indications
Reasons for noncompliance
Conclusion
Acknowledgments
Appendix 1Data collection form
Appendix 2Guidelines to assist with the assessment of appropriateness
Appendix 3Guidelines to assist with the assessment of concordance with guidelines
Glossary
Antimicrobial Prescribing Practice in Australia1
Executive summary
ThisNational Antimicrobial Prescribing Survey (NAPS) Report provides insights into prescribing practices for antimicrobialsin 151Australian hospitals. It will inform quality improvement strategies, at the hospital level, for appropriate prescribing.Thereport identifies a range of opportunities for intervention at a hospital, regional and national level to improve prescribing practice in Australian hospitals.
First trialled in 2011, the NAPS conducted in 2013 used an online survey tool for the first time.The tool useda standardised audit process, withlocal auditors, and a ‘snapshot’ approachthat could be easily accessed and used by all types of healthcare facilities. This approach enableshealthcare facilitiesto review how well theirantimicrobial prescribing practices align with a predefined matrix,so that they can judge theappropriateness of prescribing,and its compliance with national or local guidelines. Systemic and topical antimicrobial agents of all types—antibacterials, antifungals and antivirals—were captured in the NAPS.
A total of 151 hospitals (132publicand 19 private) contributeddata,fromevery stateand territory. Thisresultedin a dataset of approximately 12800individual prescriptions for 7700patients. Approximately half of all large public hospitalsin Australia participated.However,participation from smaller hospitalswas much lower. The most common type ofsurveyperformed was a whole-hospital point prevalencesurvey (44%), followed bysurveys of selected wards or specialties (26%),whole-hospital periodprevalencesurveys (22%) and surveys of randomlyselected patients (8%). More than one-third (38%) of participating hospitals completed their survey in a 24hour period, while one-fifth (21%) took more than a month to complete the survey. Overhalf ofall auditors were pharmacists(53.0%);other auditors included infection control practitioners (16.8%)and medical practitioners (13.2%).
Of all the instances of prescribing recorded in the NAPS, 70.9% had a clinical indication documented in the medical record (more than 95% is considered best practice). Of all prescriptions, 70.8% were deemed to be appropriate (either optimal or adequatepractice), where such a judgment could be made. The appropriateness of the top five most commonly prescribed agents was between 60 and 76%. Only half of the cephalexin prescriptions were deemed appropriate, but higher rates of appropriateness were seen with the narrow-spectrum agents such as flucloxacillin, benzylpenicillin and vancomycin.
The most common indications weresurgical prophylaxis, community-acquired pneumonia, urinary tract infections, cellulitis/Erysipelas and Chronic Obstructive Pulmonary Disease (COPD).Inappropriate prescribing appeared to be particularly high (46%) in the treatment of acute exacerbations of COPD. Overall, only 59.7% of prescriptions were compliant with guidelines.
The most common reason for inappropriateness was use of an antimicrobial with too broad a spectrum.
Prophylactic use of antimicrobials in association with surgery was the commonest clinical indication overall. Surgical prophylaxis was given for more than 24 hours in 41.5% of cases (less than 5% is considered best practice). In contrast, medical prophylaxis was generally well prescribed, with more than 80% of prescriptions deemed appropriate.
The Australian Commission on Safety and Quality in Health Care will consider developingaClinical Care Standard for antimicrobial use in surgical prophylaxis, as it was the highest indication for antibiotic use. The Commission will also consider appropriate action with regard to COPD.
The most commonprescriptions were for ceftriaxone, which was considered inappropriate in 34% of cases, and cephazolin, which was the principal agent used for surgical prophylaxis.Cephalexin appeared to be the most inappropriately prescribed drug (39% inappropriate).
Antimicrobial Prescribing Practice in Australia1
Background
Timely, accurate and comprehensive surveillance of antimicrobial resistance and antibiotic useis central to efforts to prevent and contain the spread of resistancenationally and globally. General awareness of bacteria that are resistant to multiple antimicrobials, and the potential threat that they pose to health, is increasing. Australian governments have recognised the importance of strategies to respond to antimicrobial resistance,and encourage the appropriate use of antimicrobials to minimise the development of resistance. The World Health Organization has identified this issue as critical and has called on all countries to control antimicrobial use as a major risk factor. Internationally, the literature indicates that up to 75% of patients in hospitals and health facilities will receive an antibiotic, and that 25–50% of these prescriptions are inappropriate (Van de Sande-Bruinsma et al 2008[1]).
Antimicrobial stewardship is the coordinated effort to improve the quality and safety of antimicrobial use. In 2011, the Australian Commission on Safety and Quality in Health Care recommended thatantimicrobial stewardshipprograms be established in all hospitals (Duguid & Cruickshank 2011[2]).In 2013,antimicrobial stewardshipbecame an accreditation criterion in the National Safety and Quality Health Service (NSQHS) Standards. All hospitalsin Australia are now required to audit and monitor antimicrobial prescribing.
TheNational Antimicrobial Prescribing Surveys(NAPS) are conducted by the Melbourne HealthAntimicrobial Stewardship Research Team. The Surveyswere designed as a voluntary annual audit to be undertaken by healthcare professionals in participating hospitals, allowing them to take a snapshot sample of their medication charts and patient records, to assess the appropriateness of prescribing.
The2013 NAPSaims to build a more comprehensive picture of antimicrobial prescribing practices in Australian hospitals. It:
•provides a tool to
–assist healthcare facilitiesto audit antimicrobial prescribing practicesina meaningful way
–facilitatelocal quality improvement
•allowsa variety of auditors with different levels ofexperiencetoperform both quantitativeandqualitativeassessments of antimicrobial prescribing
•providesdata onantibiotic prescribingbehaviour inAustralianhospitals so that comparisons can be made betweenparticipating hospitals (depending onpatientselectionstrategies used by hospitals)
•supportsbenchmarking,wherepossible
•helps toidentify problematicareasin which prescribingfrequently varies from recommendationsin Therapeutic Guidelines: Antibiotic,[3] or endorsed local guidelines
•helps to identifyclinical indications and antimicrobial use patterns for which interventions might be designed.
Limitations in methodology
The results presented in this report should be interpreted in the context of several constraints:
- Sampling and selection bias. Participation in the NAPS was voluntary. Hence the hospitals included in this report were not a randomised sample, and the results mightbe skewed by self-selection.
- Survey methodology. Participating facilities were able to choose their own method of data collection (e.g. pointprevalence survey, random sample, targeted patient types). This has an impact on the accuracy of some denominators.
- Validation of audit tool and assessment of appropriateness.Individual auditors at each participating facility were responsible for determining the appropriateness of each antimicrobial prescription. Although an algorithm and detailed instructions were provided, the audit tool has not yet been fully validated. An inter-auditor correlation study will be conducted to determine the consistency of assessments between auditors.
Antimicrobial Prescribing Practice in Australia1
The 2013 NAPS
Methods
Hospitalswereencouraged toconduct theNAPSduringAntibiotic Awareness Week 2013. The number of participatinghospitals has grown from 32pilotsitesin 2011 to 76in 2012; in 2013, 151hospitals participated. The first two surveys (2011 and 2012) were performed usingpaper-based data collection tools. In 2013, a comprehensive web-based survey tool was used.
Survey types
Data collection for the NAPS was designed to beas flexible and practicalas possible. Hospitalswere able to collect data usinga variety of methods:
•whole-hospital point prevalence survey
•whole-hospital periodprevalencesurvey
•survey of particular wards or specialties
•survey of a randomly selected group of patients.
Auditors
The professional status of auditors at each participating site was documented as part of the NAPS. Trainingandsupportwereprovided toauditors through videos and onlinetraining sessions, and email and telephonesupport throughouttheNAPS.
Key data fields
The key data collection fields are shown in Appendix1. Systemic and topical antimicrobial agents of all types—antibiotics (antibacterials), antifungals and antivirals—were captured in the survey. The data included whether the indication was documented, whether prophylactic use of antimicrobials in association with surgery (‘surgical prophylaxis’) was continued for more than 24hours, and whether the prescription was compliant with prescribing guidelines (Therapeutic Guidelines: Antibiotic or endorsed local guidelines). A predefined assessment matrix (Appendix2) was used to assess whether use of the antimicrobial was appropriate.
Theauditorswereaskedtoassess the overall appropriateness of each prescriptionusing theguidelinesin Appendix3.The following five options were provided:
•compliant with Therapeutic Guidelines: Antibiotic
•compliant with local guidelines
•noncompliant with guidelines
•no guidelines available
•not assessable.
General findings
Participatinghospitals
A total of 214hospitals (174 publicand 40 private) registeredfor the 2013 NAPS.Of these, 151hospitals (132 publicand 19 private) contributed data, as shown inMap 1. This compares with 76hospitalsthat contributed data in 2012and 32in 2011.
Each stateand territory was represented in the responses.
Map1Participatinghospitalsaccording to state and territory,and type
Among the participants, therewasa goodspread ofrepresentationbypeergroupand remoteness. These classifications were made in accordance with the Australian Institute of Health and Welfare report Australian hospital statistics 2011–12.
Overall, 22% ofpeer grouppublic hospitalsinAustralia participatedinthe 2013 NAPS.Thelargest proportionwas inpeer groupA(principal referral, and specialist women’s and children’s) andpeer groupB(large) hospitals, of whichapproximately half participated. Participation by smallerhospitalswas much lower.
Types of surveys performed
Figure 1 shows the types of surveys performed.Most hospitals performed a whole-hospital pointprevalencesurvey (43.8%). This wasfollowedbysurveys of selected wards or specialties (26%), whole-hospitalperiodprevalencesurveys (22%),andsurveys of arandomlyselectedgroup of patients (8%). Nohospital in 2013 performed adirectedsurvey.Seventy-three hospitals also completed a questionnaire about the process, and the usability of the NAPS and website.
Figure1Typesofsurveysperformed
Source: NAPS user evaluation surveys
Thirty-eight percent ofhospitals conducted theirsurvey over1day, 14% over 2–5days, 27% over1–4weeks and 21% overmore than a month(seeFigure2).
Figure2Period over which surveys were conducted
Source: NAPS user evaluation surveys
Types of auditors
In the 2013 NAPS, 334 auditors participated. More than half (53.0%) ofthe auditors who registered were pharmacists, followed byinfection control practitioners (16.8%)and medical practitioners (13.2%), as shown in Figure3.
Figure3Categorisation of auditors according to profession
Antimicrobial Prescribing Practice in Australia1
Specific findings on prescribing practices
Most commonly prescribed antimicrobials
The most commonly prescribed antimicrobials (see Figure4) were:
•ceftriaxone
•cephazolin (principally as surgical prophylaxis)
•metronidazole
•amoxycillin-clavulanic acid
•piperacillin-tazobactam.
Figure 4Top 20 most commonly prescribed antimicrobials
Note: The figure showsthe number of prescriptions for each antimicrobial and the percentage of the total prescriptions that this represents.
Documentation of indication
Overall, a clinical indication was documented in the medical record for 70.9% of antimicrobial prescriptions. The median was 80.9% (interquartile range [IQR]: 61.9 to 92.8%). These values fall short of the best-practice value of more than 95%. Documentation rates appeared to be higher in Queensland (87.2%) and South Australia (82.1%). Documentation was poorer in private hospitals (51.3%) than in public hospitals (72.6%).
As shown in Figure 5, prophylaxis indications such as surgical and medical prophylaxis comprised a significant proportion (19.7%) of antimicrobial prescriptions. When these indications are excluded, the overall documentation of indication improved slightly, to 75.1%.
In this report, the categories ‘Other’ and ‘Indication unknown’ have been removed from graphs and tables.
Most common indications
The most common indications were:
•surgical prophylaxis
•community-acquired pneumonia
•urinary tract infection
•cellulitis/Erysipelas
•Chronic Obstructive Pulmonary Disease (COPD).
Figure 5Top 20 most common indications
Note: The figure shows the number of documentations of each indication for which an antimicrobial was prescribed and the percentage of the total documentations that this represents.
Key indicators
Table 2 summarises the results for key indicators, including appropriateness and compliance with guidelines, for the contributing hospitals.
Table 2Results of key indicators for all contributing hospitals
Key indicator / % of total prescriptions / % of total assessable prescriptionsaIndication documented in medical notes(best practice >95%) / 70.9 / –
Surgical prophylaxis given for >24hours(best practice <5%) / 41.5b / –
Compliance with guidelines: Compliant with Therapeutic Guidelines: Antibiotic or endorsed local guidelines / 59.7 / 72.2
Compliance with guidelines: Noncompliant / 23.0 / 27.8
Compliance with guidelines: No guideline available / 11.0 / –
Compliance with guidelines: Not assessable / 6.3 / –
Appropriateness: Appropriate (optimal + adequate) / 70.8 / 75.6
Appropriateness: Inappropriate(suboptimal + inadequate) / 22.9 / 24.4
Appropriateness: Not assessable / 6.3 / –
aAssessable means that the denominator excludes antimicrobial prescriptions marked ‘Guideline not available’ or ‘Not assessable’.
bWhere surgical prophylaxis was selected as the indication (1473 prescriptions)
Antimicrobial Prescribing Practice in Australia1
Appropriateness of prescribing
Overall appropriateness
The results for all 151 contributing hospitals show that 70.8% of prescriptions were deemed to be appropriate.Excluding those prescriptions marked ‘Not assessable’, 75.6% of prescriptions were appropriate, and 24.4%were inappropriate.
Appropriateness of assessable prescriptions
A more detailed breakdown of results according topeer group, remoteness and funding type is shown in Tables3and 4.Table 3showspopulation-level percentages (analysis of all prescriptions),whileTable4showsthe median and interquartile ranges for key indicators by facility (analysis of prescriptions by facility). Note that these results aresite-level medians and do not take into account the number of contributing prescriptions per site.Importantly, prescriptions marked ‘Guideline not available’ or ‘Not assessable’ areexcluded from the denominators for compliance with guidelines and appropriateness.
No statistically significant differences were found between peer groups and remoteness area classifications.
Antimicrobial Prescribing Practice in Australia1
Table 3Key indicators, according to peer group, remoteness and funding type
Number of hospitals / Number of prescriptions / Indication documented (%) / Surgical prophylaxis >24hours (%)a / Compliance with guidelines: Compliant (%) / Compliance with guidelines: Noncompliant (%) / Compliance with guidelines: Not available (%) / Compliance with guidelines: Not assessable (%) / Appropriateness: Appropriate (%) / Appropriateness: Inappropriate (%) / Appropriateness: Not assessable (%)Peer group (public hospitals only): A / 54 / 8633 / 72.3 / 46.1 / 58.7 / 22.3 / 13.5 / 5.4 / 71.1 / 23.4 / 5.5
Peer group (public hospitals only): B / 20 / 1266 / 77.0 / 45.0 / 59.9 / 26.2 / 6.4 / 7.4 / 71.0 / 22.5 / 6.5
Peer group (public hospitals only): C / 25 / 1129 / 65.6 / 13.3 / 65.0 / 24.0 / 3.1 / 7.9 / 71.6 / 20.8 / 7.6
Peer group (public hospitals only): D / 22 / 605 / 70.8 / 53.9b / 66.6 / 23.8 / 5.1 / 4.5 / 73.7 / 22.7 / 3.6
Peer group (public hospitals only): E / 10 / 120 / 87.9 / No data / 65 / 20 / 5.8 / 9.2 / 64.2 / 24.2 / 11.7
Peer group (public hospitals only): F / 0 / 0 / No data / No data / No data / No data / No data / No data / No data / No data / No data
Peer group (public hospitals only): G / 2 / 36 / 91.7 / No data / 97.2 / 0 / 2.8 / 0 / 88.9 / 2.8 / 8.3
Remoteness (public hospitals only): Major cities / 65 / 8742 / 74.0 / 47.6 / 58.2 / 22.2 / 14.0 / 5.6 / 71.4 / 23.0 / 5.6
Remoteness (public hospitals only): Inner regional / 46 / 1933 / 66.5 / 25.3 / 65.8 / 26.0 / 1.9 / 6.3 / 71.6 / 22.2 / 6.2
Remoteness (public hospitals only): Outer regional / 14 / 654 / 67.3 / 45.5b / 59.0 / 24.8 / 6.6 / 9.6 / 65.8 / 24.5 / 9.8
Remoteness (public hospitals only): Remote / 6 / 426 / 73.5 / 66.7b / 71.6 / 21.1 / 4.9 / 2.4 / 75.6 / 23.2 / 1.2
Remoteness (public hospitals only): Very remote / 2 / 34 / 85.3 / No data / 67.7 / 23.5 / 5.9 / 2.9 / 76.5 / 23.5 / 0.0
Funding type: Public / 132 / 11789 / 72.6 / 42.9 / 60.2 / 22.8 / 11.2 / 5.8 / 71.3 / 22.9 / 5.8
Funding type: Private / 19 / 1021 / 51.3 / 38.2 / 54.1 / 25.5 / 9.1 / 12.3 / 65.0 / 22.2 / 12.7
Combined national result / 151 / 12810 / 70.9 / 41.5 / 59.7 / 23.2 / 10.9 / 6.3 / 70.8 / 22.9 / 6.3
a Where surgical prophylaxis was selected as the indication (1473 total prescriptions)
b Low numbers of surgical prophylaxis prescriptions (<30)
Table 4Median and interquartile ranges of key indicators, according to state or territory, peer group, remoteness and funding type
Number of hospitals / Indication documented (%), n=12810 / Surgical prophylaxis >24hours (%), n=1473 / Compliance with guidelines (n = 10599): Complianta(%) / Compliance with guidelines (n=10599): Noncomplianta(%) / Appropriateness (n=12001): Appropriatea(%) / Appropriateness (n=12001): Inappropriatea(%)Peer group (public hospitals only): A / 54 / 79.6 (62.5, 88.9) / 50 (17.6, 66.7) / 73.2 (61.2, 85.3) / 26.8 (14.7, 38.8) / 75.2 (67.7, 83.9) / 24.8 (16.1, 32.3)
Peer group (public hospitals only): B / 20 / 80.9 (68.2, 92.8) / 66.7 (5, 100) / 76.9 (51.5, 81.8) / 23.1 (18.2, 48.5) / 78.8 (60.8, 84.9) / 21.2 (15.1, 39.2)
Peer group (public hospitals only): C / 25 / 77.4 (41.9, 87.5) / 13.2 (0, 37.5) / 76.1 (61.4, 92.9) / 23.9 (7.1, 38.6) / 84.4 (68.8, 92.6) / 15.6 (7.4, 31.3)
Peer group (public hospitals only): D / 22 / 98.4 (68.2, 100) / 29.2 (0, 58.3) / 67.5 (44.4, 100) / 32.5 (0, 55.6) / 73.9 (50, 81.0) / 26.1 (19.0, 50)
Peer group (public hospitals only): E / 10 / 100 (88.4, 100) / No data / 75.9 (75, 100) / 24.0 (0, 25) / 73.0 (66.7, 100) / 27.0 (0, 33.3)
Peer group (public hospitals only): F / 0 / No data / No data / No data / No data / No data / No data
Peer group (public hospitals only): G / 2 / 95.7 (91.4, 100) / No data / 98.6 (97.1, 100) / 1.4 (0, 2.9) / 98.4 (96.9, 100) / 1.6 (0, 3.1)
Remoteness (public hospitals only): Major cities / 65 / 82.5 (67.3, 90.7) / 50.8 (33.3, 78.0) / 73.8 (62.1, 85.4) / 26.2 (14.6, 37.9) / 76.7 (68.2, 86.0) / 25 (5.2, 36.5)
Remoteness (public hospitals only): Inner regional / 46 / 80.9 (60.9, 98.1) / 17.7 (0, 50) / 77.4 (50, 95.7) / 22.6 (4.3, 50) / 75 (63.5, 94.8) / 23.3 (14.0, 31.8)
Remoteness (public hospitals only): Outer regional / 14 / 82.9 (70, 100) / 0 (0, 81.8) / 75.5 (58.9, 89.3) / 24.5 (10.7, 41.1) / 69.0 (66.7, 77.4) / 31.0 (22.6, 33.3)
Remoteness (public hospitals only): Remote / 6 / 91.9 (68.2, 99.3) / 58.3 (0, 100) / 70.4 (51.4, 86.0) / 29.6 (14.0, 48.6) / 74.5 (65, 87.0) / 25.5 (13.0, 35)
Remoteness (public hospitals only): Very remote / 2 / 83.7 (76.9, 90.5) / No data / 75.9 (68.4, 83.3) / 24.1 (16.7, 31.6) / 75.1 (69.2, 81.0) / 24.9 (19.0, 30.8)
Funding type: Public / 132 / 82.4 (67.0, 94.0) / 50 (11.1, 74.2) / 75 (58.4, 89.0) / 25 (11.0, 41.6) / 75.2 (66.7, 86.7) / 24.8 (13.3, 33.3)
Funding type: Private / 19 / 57.1 (26.7, 82.9) / 42.7 (3.4, 50) / 73.5 (60, 91.7) / 26.5 (8.3, 40) / 76.5 (66.7, 94.7) / 23.5 (5.3, 33.3)
National total / 151 / 80.9 (61.9, 92.8) / 46.8 (5.6, 66.7) / 75.0 (58.4, 89.0) / 25 (10.7, 41.5) / 75.2 (66.7, 86.7) / 24.4 (12.8, 33.3)
a For compliance with guidelines and appropriateness, prescriptions marked ‘Guideline not available’ or ‘Not assessable’ have been excluded from the denominator.
Antimicrobial Prescribing Practice in Australia1
Appropriateness of prescriptions for prophylaxis
Nationally, 41.5% of surgical prophylaxis prescriptions were for longer than 24hours. This is substantially higher than the best-practice target of less than 5%. There were no statistically significant differences between the states and territories. The results were similar between public and private hospitals.
Surgical prophylaxis was the leading indication observed (Figure5). However, the overall burden of antibiotics prescribed for this condition is likely to be lower than suggested by the percentage of prescriptions, given that most surgical antibiotic prophylaxis is of relatively short duration. Nevertheless, surgical antibiotic prophylaxiscould be a target for future campaigns, especially given that 42% of these prescriptions were deemed to be inappropriate (seeTable7). The most commonly cited reasons for inappropriateness (Table5) were an incorrect duration, and an incorrect dose or frequency.
Table 5Reasons for inappropriateness of surgical prophylaxis prescriptions (613 prescriptions)
Reason / Yes (%) / No (%) / Not specified (%)Incorrect duration / 53.2 / 29.5 / 17.3
Incorrect dose or frequency / 20.1 / 58.7 / 21.2
Spectrum too broad / 11.6 / 60.7 / 27.7
Spectrum too narrow / 1.8 / 68.4 / 29.9
Incorrect route / 1.8 / 71.5 / 26.8
In contrast, antimicrobials for medical prophylaxis appeared to be well prescribed, with more than 80% of these prescriptions deemed to be appropriate.