Healthcare Infection Healthcare Infection Society
Official Journal of the Australasian College for Infection Prevention and Control
RESEARCH ARTICLE (Open Access)

Implementation of an antimicrobial stewardship program in an Australian metropolitan private hospital: lessons learned

Jeannine A. M. Loh A E , Jonathan D. Darby A B , John R. Daffy A B , Carolyn L. Moore A C , Michelle J. Battye A , Yves S. Poy Lorenzo D and Peter A. Stanley A B
+ Author Affiliations
- Author Affiliations

A St Vincent’s Private Hospital Melbourne, Vic. 3065, Australia.

B Infectious Diseases Unit, St Vincent’s Hospital Melbourne, Vic. 3065, Australia.

C Australian Catholic University (Honorary Clinical Fellow), Vic. 3065, Australia.

D Pharmacy Department, St Vincent’s Hospital Melbourne, Vic. 3065, Australia.

E Corresponding author. Email: jeannine.loh@svha.org.au

Healthcare Infection 20(4) 134-140 https://doi.org/10.1071/HI15015
Submitted: 17 July 2015  Accepted: 31 August 2015   Published: 14 September 2015

Abstract

Introduction: While there is literature on the implementation and efficacy of antimicrobial stewardship (AMS) programs in the public hospital setting, there is little concerning their implementation in the private hospital setting. Resources to guide the implementation of such programs often fail to take into consideration the resource limitations and cultural barriers faced by private hospitals. In this paper we discuss the main obstacles encountered when implementing an AMS program at a private hospital and methods that were used to overcome them.

Methods: In 2012, St Vincent’s Private Hospital Melbourne implemented an AMS program that was tailored to suit the requirements and limitations faced by private hospitals. Baseline data was collected to determine areas of priority. Cultural barriers were overcome by forming relationships between AMS and non-AMS personnel, involving key clinical stakeholders when developing hospital policies, and having ample support from hospital executives. We also modified our approach to conventional AMS interventions so that typically resource-intensive projects could be carried out with minimal resources, such as the restriction of antimicrobials via a two-stage post-prescription review model.

Results: Through our AMS program, we have been able to implement multiple initiatives including a formulary restriction, significantly reduce aminoglycoside use, develop hospital guidelines and regularly contribute data to national surveillance programs.

Conclusion: While there are guidelines available to help develop an AMS program, these guidelines need to be adapted to suit different hospital settings. Private hospitals present a unique challenge in the implementation of AMS programs. Identifying and addressing barriers specific to an individual institution is vital.


References

[1]  Centers for Disease Control and Prevention (CDC). Antibiotic resistance threats in the United States, 2013. Atlanta: CDC; 2013. Available from: http://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf [verified 7 April 2015]

[2]  Cosgrove SE. The relationship between antimicrobial resistance and patient outcomes: mortality, length of hospital stay, and health care costs. Clin Infect Dis 2006; 42 S82–9.
The relationship between antimicrobial resistance and patient outcomes: mortality, length of hospital stay, and health care costs.CrossRef | 16355321PubMed |

[3]  Tsang JK, Tsang OT, Yao R, Lai S. The Antimicrobial Stewardship Programme: where have we been...where are we going? World Hosp Health Serv 2013; 49 18–21.
| 24228343PubMed |

[4]  Ohl CA, Luther VP. Antimicrobial stewardship for inpatient facilities. J Hosp Med 2011; 6 S4–15.
Antimicrobial stewardship for inpatient facilities.CrossRef | 21225949PubMed |

[5]  Duguid M, Cruickshank M. Antimicrobial stewardship in Australian hospitals. Canberra: Commonwealth of Australia; 2011. Available from: http://safetyandquality.gov.au/wp-content/uploads/2011/01/Antimicrobial-stewardship-in-Australian-Hospitals-2011.pdf [verified 25 February 2015]

[6]  Nowak MA, Nelson RE, Breidenbach JL, Thompson PA, Carson PJ. Clinical and economic outcomes of a prospective antimicrobial stewardship program. Am J Health Syst Pharm 2012; 69 1500–8.
Clinical and economic outcomes of a prospective antimicrobial stewardship program.CrossRef | 22899745PubMed |

[7]  Malcolm W, Nathwani D, Davey P, Cromwell T, Patten A, Reilly J, Cairns S, Bennie M. From intermittent antibiotic point prevalence surveys to quality improvement: experience in Scottish hospitals. Antimicrob Resist Infect Control 2013; 2 3
From intermittent antibiotic point prevalence surveys to quality improvement: experience in Scottish hospitals.CrossRef | 23320479PubMed |

[8]  Feazel LM, Malhotra A, Perencevich EN, Kaboli P, Diekema DJ, Schweizer ML. Effect of antibiotic stewardship programmes on Clostridium difficile incidence: a systematic review and meta-analysis. J Antimicrob Chemother 2014; 69 1748–54.
Effect of antibiotic stewardship programmes on Clostridium difficile incidence: a systematic review and meta-analysis.CrossRef | 1:CAS:528:DC%2BC2cXhtVWms73N&md5=bef483d73daeedebfb05552d0af28297CAS | 24633207PubMed |

[9]  Rosa RG, Goldani LZ, dos Santos RP. Association between adherence to an antimicrobial stewardship program and mortality among hospitalised cancer patients with febrile neutropenia: a prospective cohort study. BMC Infect Dis 2014; 14 286
Association between adherence to an antimicrobial stewardship program and mortality among hospitalised cancer patients with febrile neutropenia: a prospective cohort study.CrossRef | 24884397PubMed |

[10]  Davey P, Brown E, Charani E, Fenelon L, Gould IM, Holmes A, Ramsay CR, Wiffen PJ, Wilcox M. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2013; CD003543
Interventions to improve antibiotic prescribing practices for hospital inpatients.CrossRef | 23633313PubMed |

[11]  Australian Commission on Safety and Quality in Health Care. Safety and Quality Improvement Guide Standard 3: Preventing and Controlling Healthcare Associated Infections, October 2012. Sydney: ACSQHC; 2012. Available from: http://www.safetyandquality.gov.au/wp-content/uploads/2012/10/Standard3_Oct_2012_WEB.pdf [verified 25 February 2015]

[12]  Huttner B, Harbarth S, Nathwani D. (European Society of Clinical Microbiology and Infectious Diseases). Success stories of implementation of antimicrobial stewardship: a narrative review. Clin Microbiol Infect 2014; 20 954–62.
(European Society of Clinical Microbiology and Infectious Diseases). Success stories of implementation of antimicrobial stewardship: a narrative review.CrossRef | 1:STN:280:DC%2BC2M7ot1Whsg%3D%3D&md5=a15847358907a09d52a2a976268d61b5CAS | 25294340PubMed |

[13]  James RS, McIntosh KA, Luu SB, Cotta MO, Marshall C, Thursky KA, Buising KL. Antimicrobial stewardship in Victorian hospitals: a statewide survey to identify current gaps. Med J Aust 2013; 199 692–5.
Antimicrobial stewardship in Victorian hospitals: a statewide survey to identify current gaps.CrossRef | 24237101PubMed |

[14]  Australian Government Productivity Commission. Public and Private Hospitals, Research Report. Canberra; Australian Government; 2009. Available from: http://www.pc.gov.au/inquiries/completed/hospitals/report/hospitals-report.pdf [verified 25 February 2015]

[15]  Charani E, Castro-Sanchez E, Sevdalis N, Kyratsis Y, Drumright L, Shah N, Holmes A. Understanding the determinants of antimicrobial prescribing within hospitals: the role of ‘prescribing etiquette’. Clin Infect Dis 2013; 57 188–96.
Understanding the determinants of antimicrobial prescribing within hospitals: the role of ‘prescribing etiquette’.CrossRef | 1:STN:280:DC%2BC3srjvVakug%3D%3D&md5=ab316e8e1a486b4efe5d3bdedccdec3fCAS | 23572483PubMed |

[16]  Cotta MO, Robertson MS, Tacey M, Marshall C, Thursky KA, Liew D, Buising KL. Attitudes towards antimicrobial stewardship: results from a large private hospital in Australia. Healthc Infect 2014; 19 89–94.
Attitudes towards antimicrobial stewardship: results from a large private hospital in Australia.CrossRef |

[17]  Chaves NJ, Cheng AC, Runnegar N, Kirschner J, Lee T, Buising K. Analysis of knowledge and attitude surveys to identify barriers and enablers of appropriate antimicrobial prescribing in three Australian tertiary hospitals. Intern Med J 2014; 44 568–74.
Analysis of knowledge and attitude surveys to identify barriers and enablers of appropriate antimicrobial prescribing in three Australian tertiary hospitals.CrossRef | 1:STN:280:DC%2BC2cbotVynsQ%3D%3D&md5=a21fd45b7ae35b593c24d8d419e18d89CAS | 25083531PubMed |

[18]  Baker R, Camosso-Stefinovic J, Gillies C, Shaw EJ, Cheater F, Flottorp S, Robertson N. Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews; 2005. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005470.pub2/pdf [verified 31 March 2015]

[19]  Cotta MO, Robertson MS, Marshall C, Thursky KA, Liew D, Buising KL. Implementing antimicrobial stewardship in the Australian private hospital system: a qualitative study. Aust Health Rev 2015; 39 315–22.
Implementing antimicrobial stewardship in the Australian private hospital system: a qualitative study.CrossRef |

[20]  Cairns KA, Jenney AWJ, Abbot IJ, Skinner MJ, Doyle JS, Dooley M, Cheng AC. Prescribing trends before and after implementing an antimicrobial stewardship program. Med J Aust 2013; 198 262–6.
Prescribing trends before and after implementing an antimicrobial stewardship program.CrossRef | 23496402PubMed |

[21]  Johannsson B, Beekmann SE, Srinivasan A, Hersh A, Laxminarayan R, Polgreen PM. Improving antimicrobial stewardship: the evolution of programmatic strategies and barriers. Infect Control Hosp Epidemiol 2011; 32 367–74.
Improving antimicrobial stewardship: the evolution of programmatic strategies and barriers.CrossRef | 21460488PubMed |

[22]  Chow A, Lye DC, Arah OA. Psychosocial determinants of physicians’ acceptance of recommendations by antibiotic computerised decision support systems: a mixed methods study. Int J Antimicrob Agents 2015; 45 295–304.
Psychosocial determinants of physicians’ acceptance of recommendations by antibiotic computerised decision support systems: a mixed methods study.CrossRef | 1:CAS:528:DC%2BC2cXhvFCnsrnE&md5=4d64a3e39752307a11856630d3b65165CAS | 25434998PubMed |

[23]  Chung GW, Wu JE, Yeo CL, Chan D, Hsu LY. Antimicrobial stewardship: a review of prospective audit and feedback systems and an objective evaluation of outcomes. Virulence 2013; 4 151–7.
Antimicrobial stewardship: a review of prospective audit and feedback systems and an objective evaluation of outcomes.CrossRef | 23302793PubMed |

[24]  Pakyz AL, Moczygemba LR, VanderWielen LM, Edmond MB, Stevens MP, Kuzel AJ. Facilitators and barriers to implementing antimicrobial stewardship strategies: Results from a qualitative study. Am J Infect Control 2014; 42 S257–63.
Facilitators and barriers to implementing antimicrobial stewardship strategies: Results from a qualitative study.CrossRef | 25239719PubMed |

[25]  Ahmed RM, Hannigan IP, MacDougall HG, Chan RC, Halmagyi GM. Gentamicin ototoxicity: a 23-year selected case series of 103 patients. Med J Aust 2012; 196 701–4.
Gentamicin ototoxicity: a 23-year selected case series of 103 patients.CrossRef | 22554194PubMed |

[26]  Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2014.

[27]  Broom A, Broom J, Kirby E. Cultures of resistance? A Bourdieusian analysis of doctors’ antibiotic prescribing. Soc Sci Med 2014; 110 81–8.
Cultures of resistance? A Bourdieusian analysis of doctors’ antibiotic prescribing.CrossRef | 24727665PubMed |

[28]  Sevinç F, Prins JM, Koopmans RP, Langendijk PNJ, Bossuyt PM, Dankert J, Speelman P. Early switch from intravenous to oral antibiotics: guidelines and implementation in a large teaching hospital. J Antimicrob Chemother 1999; 43 601–6.
Early switch from intravenous to oral antibiotics: guidelines and implementation in a large teaching hospital.CrossRef | 10350396PubMed |

[29]  Ramirez JA, Vargas S, Ritter GW, Brier ME, Wright A, Smith S, Newman D, Burke J, Mushtaq M, Huang A. Early switch from intravenous to oral antibiotics and early hospital discharge. A prospective observational study of 200 consecutive patients with community-acquired pneumonia. Arch Intern Med 1999; 159 2449–54.
Early switch from intravenous to oral antibiotics and early hospital discharge. A prospective observational study of 200 consecutive patients with community-acquired pneumonia.CrossRef | 1:STN:280:DC%2BD3c7islKmuw%3D%3D&md5=c65e81fe694e9d27cd36c8ff5c2e4dd6CAS | 10665893PubMed |

[30]  Mertz D, Koller M, Haller P, Lampert ML, Plagge H, Hug B, Koch G, Battegy M, Fluckiger U, Bassetti S. Outcomes of early switching from intravenous to oral antibiotics on medical wards. J Antimicrob Chemother 2009; 64 188–99.
Outcomes of early switching from intravenous to oral antibiotics on medical wards.CrossRef | 1:CAS:528:DC%2BD1MXntlGgsLc%3D&md5=b24aa13b55bacf09929556fa41b2510dCAS | 19401304PubMed |

[31]  Duane TM, Zuo JX, Wolfe LG, Bearman G, Edmond MB, Lee K, Cooksey L, Stevens MP. Surgeons do not listen: evaluation of compliance with antimicrobial stewardship program recommendations. Am Surg 2013; 79 1269–72.
| 24351354PubMed |


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